In my career as a cardiometabolic physician, I mostly saw patients with familial hyperlipidemia, statin intolerance, and diabetes on referral from their primary care physicians. On occasions, I was asked to see someone with coronary artery disease without obvious risk factors. One patient highlights the impact of stress and PTSD on cardiovascular disease and the need for education on trauma-informed care.
Mary was in her late 60s and lived in a small town north of Dayton, Ohio. Her cardiologist had forwarded an extensive set of medical records and laboratory results. She had no history of hypertension, diabetes, or metabolic syndrome. Her standard lipid profile would have placed her at low risk for coronary artery disease (CAD). Lp(a) levels were normal, and she didn’t have a small dense LDL pattern.
Holding her chart, I knocked on the door and introduced myself. I immediately noticed that Mary looked much older than her stated age and displayed a flat affect. Did she have underlying depression? She was alone in the exam room, unusual in my practice as most patients had another person join them for the visit. Perhaps another clue?
I said, “I appreciate having the chance to see you today. How was your drive in? Any trouble finding me?” Mary replied in a monotone, “No, your directions were clear and the drive wasn’t too bad.” As I settled into my chair, I explained that I had reviewed her records and wanted to ask more questions. In her history, nothing was standing out until I started asking about her family. Her four siblings were still alive, in their late 60s, without heart disease. Both parents died in their mid 80s as did her aunts and uncles. I was puzzled by this since I had expected a family history of coronary disease in her first-degree relatives. I moved on to asking if she and her late husband have children.
I was looking down at her chart (still paper back then) when she answered quietly, “I had two children.” I looked up at her, put the pen down, and wanted to hear her story. Gently, I asked, “You said ‘had,’ what happened?” She teared up and then told me the horrible trauma she had experienced. Mary had two children, a son and a daughter. Her son was the owner of a small convenience store in a nearby town, married with three children. According to witnesses, on a routine day, two men in masks wielding handguns came into the store, demanded he hand over the money from the cash register, and at gunpoint forced him to open the safe. The robbers escaped, taking Mary’s handcuffed son with them as a hostage. An employee was able to write down the license plate of the car as it sped off. As the hours ticked away, there was no sight of the car or the men. Later that evening, someone spotted a car on fire. When the police and firefighters arrived, although the car was engulfed in flames, they were able to match the license plate to the robber’s car. After extinguishing the fire, they saw that no one was inside the car. When they popped open the trunk, they discovered the burned body of Mary’s son.
At this point in telling the story, tears were running down Mary’s cheeks. All I could say initially was how sorry I was. After a moment, I asked if she had ever shared her trauma with any of her physicians. She said no, but emphasized that no one had ever asked her about her children. Thus, there was no referral made for counseling or starting an SSRI years prior when this all happened. Her symptoms were consistent with PTSD: nightmares, depression, and other symptoms. I explained what PTSD is, how it affects the body, and that it can cause heart disease. She didn’t want to see a psychologist. When we concluded, I walked her out of the room telling her that I would send my consultation letter to her physicians, stating that, in my opinion, PTSD was the likely contributor to her CAD and recommending she be referred for counseling.
As she left, I stood there hoping that she might rethink her decision not to seek help. I couldn’t help but think of my own situation. At that time, I was seeing a psychiatrist for help with depression and PTSD stemming from childhood trauma.
PTSD is very common. In 2020, about 13 million Americans had diagnosed PTSD. Many others have undiagnosed PTSD. One study estimated that 11% of patients in a primary care setting met criteria but were not diagnosed with the disorder. There is a significant gender difference for PTSD, with women having a lifetime prevalence of around 9.7%, more than twice the 3.6% lifetime prevalence for men. In victims (80% were women) of sexual assault, 74.8% met the criteria for PTSD at one month post assault, with nearly 42% still meeting PTSD criteria at 12 months. In addition, PTSD is more common among female veterans (13%), who have twice the rate of developing PTSD compared to their male colleagues (6%).
PTSD symptoms result when traumatic events or abuse cause an ongoing overreactive “fight or flight” syndrome, arising from a disordered relationship among the pituitary gland, the hypothalamus, and the adrenal glands. These patterns of hormonal dysfunction persist long after the event that triggered the imbalance. Unfortunately, there are no definitive treatments that can prevent the development of PTSD, although CBT may help prevent it in some patients.
Most PTSD symptoms begin immediately after the event, but as many as 25% of trauma victims have delayed-onset PTSD, with symptoms appearing six months or longer after the event. Why are there delays or omissions in diagnosing PTSD? Patients may avoid bringing up the subject or may have suppressed the trauma, especially if it occurred during childhood. Clinicians may attribute PTSD symptoms to other comorbidities. Plus, the main focus in behavioral health screening in primary care has been on depression and substance abuse of tobacco, alcohol, and drugs, without a clear appreciation that a traumatic event leading to PTSD may be an underlying issue. Time constraints, lack of training, and the absence of a universal mandate for incorporating PTSD screening all contribute to delayed or missed diagnoses. Early intervention and treatment are usually associated with improved outcomes.
To address these gaps in practice patterns, trauma-informed care (TIC) has been introduced as a holistic approach to health care, shifting the focus from only asking a patient what’s wrong to also questioning what’s happened to them. TIC education is intended to help clinicians recognize that trauma exposure is common and that it can be the root cause of depression and substance abuse and can be successfully treated with various forms of behavioral therapy and medications. One of the tenets of TIC is providing a safe and comfortable environment for patients to share their experiences across the continuum of care.
Screening questionnaires for depression have been validated and used for years. The Primary Care PTSD Screen for DSM-5 is a 5-item screen designed to identify patients with PTSD. The short questionnaire can be incorporated into an annual visit in the office or as part of pre-visit questioning done routinely through EMR portals. Individuals who acknowledge exposure to trauma and have symptoms could then be referred to a counselor for further assessment.
In my situation, the primary care physician I had seen early on had no interest in discussing my childhood abuse or my trauma in dealing with an older brother with schizophrenia. I left his practice and began seeing a physician who genuinely listened to me, and was understanding and compassionate. When I began seeing a psychiatrist in 2001, I naively thought treatment would take only a few months of counseling; however, it turned into seven years of ongoing CBT with multiple medication adjustments. Like others, I struggled to openly admit to having PTSD. Somehow, it was easier to hide behind the label of being treated for depression instead of PTSD. There was no “ah-ha” moment when I started freely saying that I had PTSD, but when I did, it was surprisingly liberating to no longer hide what had happened to me. You see, it really wasn’t my fault, and I had done nothing wrong.
As for Mary, I thought of her often over the years and wondered how she had fared. We don’t know what her course might have been if her doctor had dug deeper into her history when she complained of not sleeping well and screened her for PTSD. Despite PTSD being associated with a higher mortality risk and shortened life span, it’s possible that Mary could be living a long life with the disorder, similar to some war veterans with PTSD. Mary never returned to my practice, but my hope is that she’s found the care and peace she needs.
Have you dealt with patients with PTSD in your practice? Share in the comments.
Patient name and identifying details have been modified to protect privacy.
Lawrence Mieczkowski, MD, graduated from the University of Cincinnati College of Medicine in 1982. He completed his internal medicine residency at Pittsburgh Medical Center-Mercy, then spent two years in a research role at the University of Cincinnati Lipid Research Division. Until his retirement in 2018, Dr. Mieczkowski saw patients with cardiometabolic disorders and was a sought after speaker across the country. Dr. Mieczkowski’s memoir about his life dealing with PTSD, “The Room on the Right,” was released on June 3. Visit his website at lawrencemieczkowski.com.
Illustration by April Brust
