Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization

General Hospital Psychiatry 27 (2005) 392 – 399

Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization Karen L. Gillock, Ph.D.T, Claudia Zayfert, Ph.D., Mark T. Hegel, Ph.D., Robert J. Ferguson, Ph.D. Department of Psychiatry, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756-0001, USA Received 5 January 2005; accepted 1 June 2005

Abstract Objective: This study estimates the prevalence of posttraumatic stress disorder (PTSD) and describes the relationships among PTSD status and health indices in a civilian primary care patient sample. Methods: Participants (N = 232) completed a paper-and-pencil survey of life events, PTSD symptoms, physical symptoms and health functioning. Utilization was assessed from medical records. Results: Nine percent of the participants met the criteria for full PTSD (based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) and another 25% were defined as partial PTSD. The full-PTSD group evidenced higher rates of medical utilization, more intense physical symptoms and poorer health functioning than the no-PTSD group. The partial-PTSD group more closely resembled the full-PTSD group. Conclusions: This study, although limited by sample size and diagnosis by questionnaire vs. diagnostic interview, suggests research directions for enhancing our understanding of PTSD among civilian primary care patients and for developing appropriate interventions that can be conducted in the primary care setting. D 2005 Elsevier Inc. All rights reserved. Keywords: Posttraumatic stress disorder; Primary care; Partial PTSD; Physical health; Medical utilization

1. Introduction Individuals with posttraumatic stress disorder (PTSD) are more likely to be seen in medical rather than mental health settings [1–3]. Higher rates of PTSD are noted in many medical populations, such as those with obstetric/gynecological problems [4], acute respiratory distress syndrome [5], cancer [6] and chronic pain [7]. Studies of PTSD in these populations have found higher rates of medical service utilization and poorer physical health indices among patients with PTSD symptoms than those without symptoms. To date, we have identified only three research studies that have examined prevalence rates of PTSD in general, civilian primary care populations. Taubman-Ben-Ari et al. [8] collected data from almost 3000 randomly selected patients in Israeli primary care clinics. Using the self-report PTSD Inventory [9], 9% met the criteria for PTSD. In the T Corresponding author. Tel.: +1 603 650 7520; fax: +1 603 650 5842. E-mail address: [email protected] (K.L. Gillock). 0163-8343/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2005.06.004

Primary Care Anxiety Project [10,11], a multisite study of anxiety disorders in approximately 1500 patients using a structured clinical interview, 12% of the patients met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for PTSD. McQuaid et al. [12] and Stein et al. [13] interviewed 132 primary care patients by telephone with the Comprehensive International Diagnostic Interview — Version 2.1 (CIDI) [14,15]. Of these, 11% met the current full-PTSD criteria and 2% met the criteria for current partial PTSD. Distinguishing between partial and full PTSD, as was done in the Stein et al. study [12,13], reflects a relatively recent trend in the research. Trauma reactions can be thought of as a continuum ranging from a normal reaction to stress all the way to diagnosable, full PTSD, with partial PTSD somewhere in between [16 –19]. Partial PTSD has been associated with significant impairment and/or helpseeking behavior in groups of male combat veterans [20], psychiatric outpatients [17] and community samples [21]. No studies that we are aware of have been conducted

K.L. Gillock et al. / General Hospital Psychiatry 27 (2005) 392 – 399

utilizing an appropriately sensitive measure of partial PTSD and comparing groups of individuals with partial and full PTSD recruited from a civilian primary care setting. Individuals with PTSD are more likely to seek medical rather than mental health care [1–3], and a number of studies have documented the association of PTSD with medical service utilization. The bulk of the data has been collected from veteran samples, consistently showing high rates of medical service utilization [22–30]. In a metropolitan health maintenance organization sample, Walker et al. [31] interviewed 268 females with child maltreatment histories. Controlling for comorbid psychiatric conditions and chronic medical illness, women with PTSD symptoms had higher health care costs than those without PTSD symptoms [31]. Only the work by McQuaid et al. [12] and Stein et al. [13] has examined the relationship between PTSD and medical utilization in a general, civilian primary care sample. Compared to non-PTSD patients, both full- and partialPTSD patients were more likely to be hospitalized, were seen in the emergency room more often and were higher utilizers of outpatient care. Physical illness forms a complex relationship with the presentation of PTSD [32–34]. Disorders of cardiovascular, gastrointestinal, respiratory, musculoskeletal, endocrine, neurological, gynecological and immune system disorders are prevalent in PTSD samples [35,36]. In a civilian primary care sample, compared to anxiety-disordered patients without PTSD, those with PTSD reported significantly higher numbers of medical conditions [11]. Other physical problems that may be closely associated with PTSD symptoms are medical symptom clusters without identified pathology, for example, irritable bowel syndrome, fibromyalgia, chronic pain or chronic fatigue syndrome [25,37– 40]. Patients with PTSD have significantly more self-reported physical symptoms than those without PTSD, and the symptom categories, as expected, largely mirror the categories of medical conditions [27,32,41]. Studies have also found that patients with PTSD evidence worse functional health than patients without PTSD [42–44] or with other anxiety disorders and depression [45,46]. In the Stein et al. study of primary care patients [12,13], compared to non-PTSD patients, both full- and partial-PTSD patients reported greater functional impairment. The current study attempts to address the clear need for more research to confirm early findings about the relationships between PTSD, physical health and medical utilization in civilian primary care populations. Our first goal was to estimate the prevalence of PTSD in a civilian primary care sample. We hypothesized that we would replicate the approximate 10% current full-PTSD rate as found in other primary care studies, and further that we would find a larger partial-PTSD group. Our second goal was to describe the relationship of PTSD status to medical utilization, physical symptoms and functional health. We hypothesized that fulland partial-PTSD patients (1) would not differ from each other, and (2) would have higher utilization rates, more severe

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physical symptoms and poorer health functioning compared to patients without PTSD. Finally, we conducted exploratory regression analyses to determine which of the health/ utilization indices best predicted PTSD status and severity. 2. Methods 2.1. Participants Participants were drawn from among patients presenting for medical appointments at two primary care clinics associated with a medical center in rural New England. Patients were excluded if they were under 18 years of age, over 60 years of age or pregnant to reduce extraneous variance in this small sample associated with normal health care increases associated with age and pregnancy. Participants were also required to have received their primary care at the study site for at least the past year to enable data collection on medical utilization over the preceding 3 months and on medical history. 2.2. Procedures All persons in the clinic waiting rooms were eligible, whether they had an appointment or were simply accompanying a patient, if they met all the study inclusion/exclusion criteria. This was done to avoid biasing the sample toward primary care patients who were ill. The nature and purpose of the study were explained and written informed consent was obtained. Upon completion of the survey, researchers debriefed participants and provided contact information in the event of questions or untoward effects. These procedures were approved by the IRB committee. 2.3. Measures 2.3.1. Posttraumatic stress disorder Two measures were used to define PTSD. The first was the PTSD Checklist — Civilian Version (PCL) [47], a 17-item self-report inventory for assessing the severity of the 17 DSM-IV criteria B, C and D symptoms of PTSD over the past month using a five-point Likert scale. Reported measure statistics include test–retest reliability of 0.96, internal consistency a’s of .90 –.94 for B symptoms, .82–.92 for C symptoms, .84 –.92 for D symptoms and .94–.97 for the total score [47,48]. Additional items designed by the second author (available upon request) were used to assess DSM-IV criteria E and F. The second measure was the Life Events Checklist (LEC), part of the Clinician-Administered PTSD Scale [49], a self-report 17-item listing of traumatic experience categories, including natural disaster, transportation accident, physical assault, sexual assault, combat or exposure to a war zone, sudden violent death (i.e., homicide, suicide), and other very stressful events or experiences. Respondents were also asked to provide brief details about their bmost traumatic event,Q including the experience of fear, helplessness or horror.

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2.3.2. Medical utilization Utilization was measured as the number of medical visits for the 3 months preceding the visit/date in which the participants were surveyed. This was determined via review of patients’ medical records. Visits were defined as any medical appointment to any general or specialty clinic that involved interaction with a physician or nurse. Laboratory procedures, appointments with allied health professionals (i.e., nutritionist), same-day surgeries, inpatient hospitalizations and outpatient psychiatric visits were not included. 2.3.3. Physical symptoms The Wahler Physical Symptom Inventory (WPSI) [50] is a brief self-report measure of the level or intensity of 42 physical symptoms or somatic complaints selected for their diagnostic importance for individuals with psychiatric disorders. Respondents indicate the frequency with which they have been bothered by each symptom using a Likert scale from 0 (almost never) to 5 (nearly every day). Higher scores indicate greater intensity of physical symptoms. The measure has demonstrated acceptable internal consistency, temporal stability and validity [50]. 2.3.4. Health functioning The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) is a widely used self-report measure of health functioning [51,52]. In the present study, only the four physical health scales (Bodily Pain, Role Limitations Due to Physical Problems, General Health Perception and Physical Functioning) were utilized due to time/resource constraints, each measured on a 0–100 scale, with higher scores indicative of higher functioning. Scores are presented as T scores (mean =50, S.D. =10) standardized to the sample (N =2474) of the 1994 general US population [52]. 2.4. Defining PTSD The independent variable, PTSD (Table 1), was objectively defined using both the PCL and LEC, and was Table 1 PTSD diagnostic criteria, as per the DSM-IV (American Psychiatric Association, 1994) A1. Exposure to an event that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others. A2. The person’s response to the event involved intense fear, helplessness or horror. B. Persistent reexperiencing symptoms: intrusive recollections, distressing dreams, flashbacks, emotional upset at reminders and physical reactions to reminders. C. Persistent avoidance symptoms: attempts to avoid thoughts and reminders, psychogenic amnesia, anhedonia, estrangement from others, emotional numbing and a sense of a foreshortened future. D. Persistent hyperarousal symptoms: sleep difficulty, irritability, concentration impairments, hypervigilance and exaggerated startle response. E. Duration of disturbance more than 1 month. F. Disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

measured in two ways. As a continuous variable, PTSD severity was defined as a single score derived by summing the 17 PCL items. The second definition was PTSD diagnosis, as a grouping variable with no-, partial-, and full-PTSD categories. PTSD diagnosis involved an assessment of the six PTSD DSM-IV criteria. If the participant endorsed at least one traumatic event category and completed all necessary items on the PCL, this was accepted as meeting the A1 criterion. The A2 criterion was met if the participant affirmatively endorsed any of the fear, helplessness or horror items on the LEC. Determination of criteria B, C and D was made based on participants’ endorsement of a sufficient number of items at a specific severity threshold. First, PCL items endorsed at a score of 3 (moderately), 4 (quite a bit) or 5 (extremely) were determined to meet the cutoff for severity. Secondly, the number of endorsed items for each category was summed and dichotomized as either meeting or not meeting criteria based on DSM-IV specifications (criterion B = 1 symptom, criterion C = 3 symptoms, and criterion D =2 symptoms). Criterion E was met if the duration item on the PCL was endorsed as bover 1 month.Q Finally, Criterion F was based on responses to PCL items pertaining to impairment in functioning, dichotomized similarly to criteria B, C and D. If at least one area of functioning was endorsed (i.e., at the moderate to extreme level), this variable was considered to be met. Participants were categorized as full PTSD if criteria A through F were met as outlined above and as partial PTSD if they met the Schnurr et. al. [18] definition: bcriterion A and E plus one of the following: 1) meeting criterion B and D but not C; 2) meeting criterion B and having at least one C symptom and one D symptom, or 3) having the sufficient number of criteria B, C, and D symptoms but with some or all rated as subthresholdQ (p. 480). If the participant did not meet criteria for full or partial PTSD, they were assigned to the no-PTSD group. 2.5. Analytic methods Descriptive statistics were used to describe the prevalence of PTSD in this sample. ANOVAs were used to describe PTSD group comparisons for medical utilization, physical symptom and health functioning. Discriminant analysis was used to build a model of PTSD group membership based on the observed characteristics of number of visits (medical utilization), WPSI scores (physical symptoms) and the four SF-36 scale scores (health functioning). This procedure generates a set of discriminant functions based on linear combinations of the predictor variables that provide the best discrimination between the groups. We chose this over logistic regression as our main interest was to find a combination of independent variables that maximized group differences in order to predict group membership rather than investigating the degree of relationship among variables. As such, the emphasis was on group status (no-, partial- or fullPTSD). However, to describe the degree of relationship

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criteria for PTSD. No differences between the groups were noted in terms of age, race or gender. Compared to the fulland partial-PTSD groups, the no-PTSD group reported more years of education [ F(2,224) =9.00, P b.001 (no = 15.40, partial = 13.91, full = 13.474)]. Persons with full or partial PTSD, compared to those with no PTSD, were more likely to live alone rather than be married/in a committed relationship (v 2 = 7.29, P b.05) and to be unemployed, retired or a homemaker rather than working outside the home (v 2 = 18.33, P b.01). 3.3. Health variables — group comparisons Fig. 1. Graphic representation of SF-36 scale T scores means for the three PTSD groups (n = 215).

among the variables, we also performed a stepwise multiple regression using the health variables (WPSI scores, SF-36 scale scores and medical visits) as the independent variables and PTSD symptom severity scores as a continuous dependent variable. 3. Results 3.1. Sample The total number of eligible participants approached was 627. The reasons given by 210 (33%) for nonparticipation included physical reasons, personal reasons, unwillingness to have medical records accessed and familiarity with researchers. Of the remaining 417 potential participants, 123 (29%) did not provide useable data because the time between registration and physician availability was too short to complete the entire survey. Another 62 (15%) surveys were discarded, primarily because insufficient data were provided to make a PTSD diagnosis. Thus, 232 (56% of potential) participants completed the survey and are represented in this data set. Participants were predominantly female (69%), Caucasian (95%; similar to the racial distribution of the geographic area), married (70%) and employed full-time (71%). The mean age of the group was 41.91 years (S.D. = 10.45, range 18–60), and mean years of education was 14.87 (S.D. =2.79, range 8–26). 3.2. PTSD rates Using the criteria outlined above, 21 (9%) of the participants met the criteria for full PTSD, 57 (25%) met the criteria for partial PTSD and 154 (66%) did not meet the

The number of outpatient medical visits over the 3-month timeframe of the study for the entire sample ranged from 0 to 12 (mean =2.56; S.D. = 2.35), and the distribution was found to have a significant negative skew ( 2.0). There were several options for dealing with this: (1) trimming 5% off the top of the data set to eliminate outliers, (2) excluding medical conditions that generate large numbers of visits (thus closely related to option 1), (3) nonparametric testing (not optimum due to power loss associated with this type of testing) and (4) transforming the data (not recommended due to potential alterations in the meaning of the data). Option 1, eliminating the outliers (top 5% of the data set — those with 8–12 outpatient visits), reduced the data set by only 10 participants (five from the no-PTSD group, two from the partial-PTSD group and three from the full-PTSD group). This reduction did not change the percentage distribution of PTSD categories but did change the skew of the outpatient visit distribution to a more acceptable 1.09. Thus, parametric tests of significance with the health variables were conducted to test hypotheses on the sample of 222. 3.3.1. Medical utilization The number of outpatient visits in a 3-month period for this revised sample ranged from 0 to 7, with a mean of 2.20 (S.D. = 1.63). Sixteen (7%) participants had no outpatient visits during this period. A comparison of groups revealed significant differences [ F(2,219) =8.77, P b.01] with the full-PTSD group evidencing the highest number of visits (mean = 3.37, S.D. = 2.17), followed by the partial-PTSD group (mean= 2.54, S.D. =1.70) and the no-PTSD group (mean = 1.93, S.D. = 1.43). Follow-up Tukey-HSD tests revealed significant differences between the no-PTSD group and the partial- and full-PTSD groups, but no differences between the partial- and full-PTSD groups.

Table 2 Means, standard deviations and significance test results of the SF-36 scale T scores for the three PTSD groups (n = 215) Scale

No PTSD (N) n = 154

Partial PTSD (P) n = 57

Full PTSD (F) n = 21

General health (GH) Bodily pain (BP) Physical functioning (PF) Role physical (RP)

49.78 48.38 52.30 49.49

43.62 43.30 47.60 43.47

38.90 33.66 40.23 38.30

a

(.93) (.85) (.77) (.94)

P values in bold type indicate significant differences.

(1.55) (1.42) (1.29) (1.57)

(2.63) (2.41) (2.20) (2.66)

Tukey-HSD P valuea N vs. P

N vs. F

P vs. F

.001 .002 .002 .001

.000 .000 .000 .000

.124 .001 .004 .096

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Table 3 Results of discriminant function analysis — correlations of predictor variables with discriminant functions Health indices

Function 1

WPSI SF-36 Bodily Pain SF-36 Physical Functioning SF-36 Role Physical Medical utilization (no. of visits) SF-36 General Health

2 .88 .73 .65 .59 .56 .55

.02 .15 .10 .54 .21 .62

3.3.2. Physical symptoms Fifteen participants did not complete a sufficient number of WPSI items to generate a scale score (10 from the noPTSD group and 5 from the partial-PTSD group). WPSI scores ranged from 0 to 3.59 (higher scores indicating greater intensity of physical symptoms), with a sample mean of 1.08 (S.D. = .77) and a distribution within normal limits. A comparison of groups revealed significant differences [ F(2,204) = 27.01, P b.001]. The full-PTSD group evidenced the highest scores (mean= 2.00, S.D. = .80), followed by the partial-PTSD group (mean =1.32, S.D. =.61) and the noPTSD group (mean= .86, S.D. = .70). Follow-up Tukey-HSD tests revealed significant differences between all groups. 3.3.3. Health functioning The four physical health scales (Bodily Pain, Role Limitations Due to Physical Problems, General Health Perception and Physical Functioning) of the SF-36 were used as an index of functioning (higher scores indicate higher functioning). A MANOVA comparing the PTSD groups (n = 215, seven individuals — four from the no-PTSD group, two from the partial-PTSD group and one from the fullPTSD group — did not complete sufficient SF-36 items to generate scale scores) indicated significant differences [ F(8,420) = 5.97, P b.001]. Individual comparisons revealed significant differences between the groups on all four subscales [bodily pain, F(2,212) = 18.84, P b.001; role physical, F (2,212) = 11.41, P b.001; general health, F (2,212) = 11.45, P b.001; and physical functioning F(2,212) =15.98, P b.001]. Post hoc analyses comparing the three groups, along with descriptive statistics, are listed in Fig. 1 and Table 2.

3.4. Health variables — predictors of PTSD 3.4.1. PTSD group membership This analysis used data from 202 participants due to missing data (14 were missing from the no-PTSD group, 5 from the partial PTSD group, and 1 from the full-PTSD group). Two discriminant functions were calculated, with a combined v 2(12) = 63.07, P b.001. After removal of the first function, the association between groups and predictors was no longer significant [v 2(5) = 3.77, P = .58]. The two discriminant functions accounted for 94.8% and 5.2%, respectively, of the between-group variability. The first discriminant function discriminated the full-PTSD group from the no-PTSD group, with the partial-PTSD group falling in between. The second discriminant function did not discriminate any of the three groups. The loading matrix of correlations between predictors and discriminant functions, as seen in Table 3, indicates that the best predictors for distinguishing between PTSD groups (first function) are WPSI scores and SF-36 Bodily Pain and Physical Functioning scale scores (loadings less than .60 are not interpreted due to power considerations). 3.4.2. PTSD symptom severity Total PCL score was used as the index of PTSD symptom severity. The sample mean for this variable was 28.63 (S.D. = 12.61), scores ranged from 17 to 70, and the distribution was significantly negatively skewed ( 1.35). A transformation of the dependent variable was not undertaken given the high cases to independent variable ratio (34:1). Group means and standard deviations on the PCL were as follows: no-PTSD mean =22.18 (S.D. = 6.16), partial-PTSD mean = 35.93 (S.D. = 6.73) and full-PTSD mean = 58.42 (S.D. =8.21). The two independent variables that contributed significant unique variance were WPSI scores and, to a lesser extent, SF-36 Role Physical scale. Addition of the other variables did not reliably improve R 2 (Table 4). 4. Discussion The first goal of this study was to estimate the prevalence of PTSD in a civilian primary care sample. Nine percent met the criteria for current full PTSD, which is consistent with previous primary care research [8,11,12]. The second goal of this study was to describe the relationship between PTSD

Table 4 Stepwise regression of heath variables on PTSD symptom severity Model

Unstandardized coefficients

Standardized coefficients

B

S.E.

b

1 Constant WPSI 2 Constant WPSI SF-36 Role Physical

18.24 9.74 27.65 8.30 .166

1.26 0.95 4.49 1.15 0.076

.58 .50 .15

t 14.42 10.21 6.16 7.20 2.18

Variables entered included medical utilization, physical symptoms measure and health functioning scales.

P

R

R2

Adj. R 2

.000 .000 .000 .000 .030

.59

.34

.34

.60

.36

.35

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status and health variables in primary care patients. Individuals with PTSD had poorer self-reported health and higher rates of medical service utilization than their nonPTSD counterparts [12,13,24,25,29,53]. Compared to those individuals without PTSD, patients with full and partial PTSD were noted to have significantly more medical visits in the 3-month period of the study, more severe physical symptoms and poorer health functioning in the domains of bodily pain, role limitations, general health perceptions and physical functioning. Within the health variable comparisons, we expected to find no differences between the partial- and full-PTSD groups. This hypothesis was generally supported. The fullPTSD group reported more intense physical symptoms, including pain, and worse physical functioning than the partial-PTSD group, but the groups were similar in number of medical visits and perceptions of their general health and role limitations due to physical problems. Thus, while patients with partial PTSD did not report quite as much physical difficulty, they rated their health to be as bad and went to the doctor as often as patients with full, diagnosable PTSD. Partial- and full-PTSD groups were also similar in that they both consistently evidenced poorer health and higher utilization than the no-PTSD group. The no-PTSD group, although somewhat high in number of medical visits in a 3-month period compared to averages in other studies [41], was generally within normal limits on measures of physical symptoms and health functioning, while patients with partial and full PTSD generally visited the doctor much more frequently and fell below normal averages on the health measures. Finally, the no-PTSD group reported more years of education and were more often in a committed relationship and employed when compared to their partialand full-PTSD counterparts. These demographic differences also suggest that the individuals with PTSD evidence poorer general functioning, which can be related to health functioning, than those with fewer PTSD symptoms. Patients with partial PTSD were more similar to patients with full PTSD than to the no-PTSD group in terms of poorer health and greater medical utilization. These results suggest that PTSD symptom severity, rather than dichotomizing diagnostic criteria, may be more useful in identifying patients at risk for health-related problems. Improved identification would be the first step in correcting the significant under- or untreated proportion of primary care patients with PTSD [31,54,55]. PTSD symptom severity was associated primarily with intensity of physical symptoms. Although accumulating evidence shows that PTSD is a risk factor for greater medical service utilization, the health-related mechanisms through which PTSD may affect utilization are less clear. Evidence is mounting that demonstrates not only an association between PTSD and health, but that PTSD mediates the relationship between trauma and health [24,36,56–58]. Others [28,59–61] suggest that the relationship between PTSD and utilization is mediated through a number of medical

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conditions, with high utilizers (in a veteran sample) accounting for most of the effect [23]. It is also possible that PTSD may have a direct effect on utilization, independent of health status. Schnurr et al. [28] showed that, while health was a significant mediator of the relationship between PTSD and utilization in a veteran sample, a significant portion of the variance could not be explained by health. The results of the present study support the hypothesis that PTSD is a risk factor for physical complaints. The relationships among PTSD, physical symptoms and disease, and medical utilization are complex. The tendency of individuals with PTSD to seek medical intervention [1,62] is likely due to the interaction of biological, behavioral and psychosocial mechanisms [4,34,36]. Traumatic stress reactions can cause biological changes and long-term physical symptoms as a result of continued nervous system activation [1,63–65]. PTSD is marked by a heterogeneous presentation that is associated with a variety of physical symptoms and medical conditions. In addition, physical problems may be directly caused by traumatic events, such as accidents or combat [32,66]. Unhealthy coping practices, such as alcohol or drug abuse, often associated with prolonged anxiety reactions of PTSD, can further lead to physical disorders and symptoms [10,67]. Comorbid psychiatric diagnoses such as anxiety and depressive disorders, or premorbid factors such as personality or gender may be related to or exacerbate physical symptoms [32,66,68]. Finally, idiosyncratic information processing may contribute to the presentation of physical symptoms, such that PTSD patients focus on and/or misinterpret somatic sensations [32]. Drawing largely from Bryant et al.’s [7] work with PTSD and chronic pain, we propose that PTSD patients may focus on somatic complaints as a result of one or a combination of the following: catastrophic interpretations of the symptoms, the exacerbation of the symptoms due to elevated anxiety levels, limited attentional control required to reduce levels of symptoms due to intrusive distress associated with PTSD and attentional bias to negative events. Often physical symptoms do not manifest for a significant period of time after the trauma has occurred or terminated [41]. Thus, PTSD patients may utilize medical services for physical complaints partially because of confusing symptom presentation and/or not recognizing the relationship between the past traumatic event(s) and present physical symptoms [41,69,70]. While primary care clinicians (PCCs) typically identify psychological symptoms in their patients, due to a variety of clinic, patient and diagnostic factors they rarely make a specific PTSD diagnosis [10,65,71]. Samson et al. [41] found that, of the patients referred by PCCs for consultation about anxiety and/or depressive symptoms (but not PTSD specifically), over one third met DSM-IV criteria for PTSD. This highlights the strong need, as suggested by many (i.e., Walker et al. [31]), for additional research to develop appropriate identification and intervention mechanisms.

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