July 1, 2004
Trauma and Health: Physical Consequences of Exposure to Extreme Stress, edited by Paula P. Schnurr and Bonnie L. Green. Published by APA, Washington, DC, 2004. Reviewed by Dennis J. Butler, professor, Medical College of Wisconsin and chair of the Trauma and Primary Care SIG.
Trauma and Health crystallizes a variety of observations made by trauma professionals about the health of their patients. It should change the way we understand the complex relationship between trauma and health and have a lasting effect on how professionals work together and respond to the traumatized patient.
This book pursues a thoughtful, comprehensive review of what is known about the relationship between trauma and health, and it articulates a way to understand the many facets of that relationship.
The book is divided into four sections followed by a fifth section that advances an integrated model supporting the position that PTSD “is the key mechanism through which trauma leads to poor health.”
The case is made that those with PTSD report poorer health status, have a greater number of reported health problems, suffer increased mortality and morbidity, are more likely to engage in high-risk behaviors and make greater use of health care resources than those without PTSD.
However, this book challenges trauma professionals to move beyond epidemiology. The editors make a strong effort to expand our understanding of the complexity and strength of the relationship between trauma and health. They leave the reader with many suggestions on how to integrate these findings clinically and in future research. With this breakthrough work, they also alert us to the many challenges and dilemmas we face when attempting to implement a biopsychosocial approach.
In an introductory chapter, the editors create the context by establishing the direct (biological) and indirect (psychological and behavioral) effects of trauma on health. The first major section focuses on physical health outcomes in traumatized patients, and three subsequent sections specifically examine psychological mechanisms, biological mechanisms and attentional/behavioral mechanisms linking trauma and health.
Within these sections are chapters that address anticipated and unexpected topics. Most clinicians and researchers likely have not attended to the costs and utilization of health care services associated with trauma, yet this enlightening chapter provides a needed perspective. The frequency of risk behavior activity and subsequent complications among trauma patients raises the alert for readers. The thorough discussion of the biologic and psychological mechanisms of allostatic load goes to the heart of our understanding of trauma. A reframing of somatoform syndromes into the concept of Multiple Ideopathic Physical Symptoms (MIPS) encourages the proverbial paradigm shift about this vexing problem. These and other chapters help to broaden the reader’s appreciation of the complex interaction between trauma and health.
As thorough as Trauma and Health is, there is one area that could benefit from a more in-depth review—the impact of trauma on children’s health. Within some chapters, research on children and trauma is reviewed, but the development of the integrative model could be strengthened if direct and indirect effects of trauma on children’s health were identified. Health and illness beliefs and behaviors are established early in life, and biological concomitants among traumatized children need to be identified.
The editors have devoted vital discussion to the logical endpoint where the trauma-health relationship is experienced and enacted—the primary care medical setting. Their consideration of the challenges is realistic, and they are clear about the daunting tasks awaiting those who wish to pursue a collaborative approach in the primary care setting. They offer reasonable suggestions for screening for PTSD in primary care settings and address the need to develop innovative training models for primary care physicians.
There is a clear need to direct research and collaborative clinical efforts at the physician’s office. The authors encourage us to move there, literally and figuratively, because most trauma victims are more likely to (repeatedly) see their physicians than contact a mental health professional. And they do so with a mutual lack of awareness. The primary care physician, burdened by time and inadequate training, doesn’t recognize the health effects of trauma; the patient doesn’t make the connection either.
As the editors note, this book is in the tradition of Selye’s work on the relationship between stress and health. They have extended that work to the trauma and PTSD arena. They show that trauma serves as a mediator between trauma and health and that the research to support this is in a formative stage. This work will give clinicians and researchers valuable evidence to further overcome dichotomous thinking about mind and body and will reinforce the necessity of a collaborative and integrated treatment philosophy.