Trauma exposure and posttraumatic stress disorder in primary care patients: cross-sectional criterion standard study.
OBJECTIVE
Posttraumatic stress disorder (PTSD) is one of the most common but least recognized anxiety disorders in primary care. This study aimed to describe the association of PTSD and trauma exposure with somatic symptoms, psychiatric comorbidity, functional impairment, and the actual treatment of PTSD in primary care.


METHODS
This cross-sectional criterion standard study included 965 consecutive primary care patients from 15 civilian primary care clinics in the United States. The Structured Clinical Interview for DSM-IV (SCID) was used to establish diagnosis of PTSD and other anxiety disorders. Somatic symptoms, depression, and anxiety were measured with the Patient Health Questionnaire (PHQ), and functional impairment was measured with the Medical Outcomes Study Short-Form General Health Survey (SF-20). The study was conducted from November 2004 to June 2005.


RESULTS
PTSD was diagnosed in 83 patients (8.6%; 95% CI, 7.0%-10.5%), and trauma exposure without fulfilling DSM-IV criteria for PTSD was reported by 169 patients (17.5%; 15.2%-20.0%). With odds ratios ranging between 2.1 (95% CI, 1.2-3.6) for headache and 9.7 (3.8-24.8) for chest pain, PTSD patients had markedly elevated somatic symptom rates compared to the reference group of patients with no PTSD or trauma exposure. PTSD was significantly associated with elevated rates of psychiatric comorbidity, pain, and impaired functioning. Patients reporting trauma but no PTSD had rates of somatic symptoms, psychiatric comorbidity, and functional impairment that were intermediate between PTSD and reference group patients. Adjusting for depression substantially attenuated the association of PTSD and trauma with somatic symptoms, suggesting that depression may be an important mediator of the PTSD-somatic symptoms relationship.


CONCLUSIONS
The high frequency of PTSD in primary care and its association with psychiatric comorbidity and functional impairment underscore the need to better detect and treat PTSD in primary care. Recognizing the frequent somatic presentation of PTSD and appreciating the salience of comorbid depression may be especially important in optimizing PTSD care.
Löwe
Bernd
B
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Klinik Hamburg-Eilbek, Hamburg, Germany. b.loewe@uke.uni-hamburg.de
Kroenke
Kurt
K
Spitzer
Robert L
RL
Williams
Janet B W
JB
Mussell
Monika
M
Rose
Matthias
M
Wingenfeld
Katja
K
Sauer
Nina
N
Spitzer
Carsten
C
D000203:Activities of Daily Living / Q000523:psychology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000150:complications / Q000469:parasitology; D016009:Chi-Square Distribution; D003430:Cross-Sectional Studies; D003863:Depression / Q000150:complications / Q000523:psychology; D005260:Female; D006261:Headache / Q000150:complications / Q000523:psychology; D006304:Health Status; D006801:Humans; D008016:Life Change Events; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011320:Primary Health Care / Q000706:statistics & numerical data; D011569:Psychiatric Status Rating Scales; D013313:Stress Disorders, Post-Traumatic / Q000150:complications / Q000175:diagnosis / Q000209:etiology / Q000523:psychology*; D055815:Young Adult