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Assessment of Trauma in Primary Care
Richard F. Mollica, MD, MAR
Harvard Medical School, Cambridge, Mass
JAMA. 2001;285:1213.
Knowledge of the acute and chronic effects of mass violence and torture is accumulating.1 The entry of millions of refugees and asylum seekers into the United States is bringing highly traumatized patients into the practices of primary care physicians. Therefore, the clinical assessment of trauma in primary care medicine has become a central issue. The primary care practitioner can assume neither that the health effects of violence will reveal themselves in the standard medical interview nor that they will be fully identified through an extensive evaluation similar to that for other organ systems. Efforts to train primary care physicians in this country and abroad have demonstrated the need for a new scientific method for assessing the clinical impact of traumatic life experiences.
In A Guide to the Physical Examination and History Taking2 and the companion pamphlet A Guide to Clinical Thinking,3 Bates et al review the approach to history taking and diagnosis in a general medical setting. This approach can be adapted into a specialized approach for the assessment and management of the health care needs of traumatized patients. This adaptation begins with a recognition of "clinical thinking as an invisible process," where "from the moment you see the patient and listen to the chief complaint, you develop ideas about what may explain the complaints and how you can determine their probable nature and cause with increasing certainty."3 It is our experience working with traumatized patients that the traumatic life events of the patient must be a central focus of clinical thinking.4 This entails considering the effects of the patient's trauma story on the medical history, physical examination, and laboratory studies.
For example, there are special considerations in evaluating the chief concern. The possibility of an organic basis to the chief complaint must be first ruled out, but the physician must also be attuned to how the patient's trauma story is contributing to the patient's physical and/or emotional distress. Very few patients can state directly that their life is "broken" or that their world has been "shattered" by horrific violent experiences.
Some physicians are reluctant to take a complete trauma history, particularly of sexual abuse, until a trusting relationship has been established. However, demonstrating to patients that their trauma story is an important component of their medical history is a significant step in establishing rapport. Private disclosure usually quickly follows from the physician's clinical interest in the patient's life experience.
For refugees and survivors of mass violence, the physician should pay particular attention to psychosocial history, particularly bereavement, and to the traumatic loss or disability of family members, especially spouses and children. The unnatural death of a child or spouse should be added immediately to the patient's problem list. Suffering after the loss of a loved one may manifest in many ways, including severe chronic depression and physical pain.
The physical exam and review of systems should be guided by information obtained during the medical interview, including the patient's trauma story.1 A mental status examination must be in the repertoire of all physicians because of the high prevalence of emotional distress in this population. Many traumatized patients cannot present their emotional distress to the physician in a coherent fashion without being emotionally retraumatized. Simple screening instruments that assess the traumatic life experiences and psychiatric symptoms of the patient in a question-and-answer format, such as the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire, can overcome this problem.5 These instruments have high cultural validity and reliability and are readily accepted by patients from diverse backgrounds.
The physician concludes the clinical assessment by developing a problem list. The patient's trauma history should be placed at the top of this list. The physician must specifically ask the patients if each of the listed medical and/or psychiatric problems have been exacerbated by their current economic or social situation. It is important to determine the negative effects of patients' illnesses on their daily life. Overall therapeutic management will consider the impact of trauma on the patient's health and functional status over time.
This new clinical assessment approach to trauma can lead to measured and realistic interventions within the context of the patient's life history. Treatment priorities must be set because not all patient problems can be solved. A well-thought-out acute and long-term treatment plan can prevent physicians from being emotionally overwhelmed by the human cruelty that has damaged their patients.
REFERENCES
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1. Goldfeld AE, Mollica RF, Pesavento BH, Faraone SV. The physical and psychological sequelae of torture: symptomatology and diagnosis. JAMA. 1988;259:2725–2729.
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2. Bates B, ed, Bickley LS, ed, Hoekelman RA, ed. A Guide to Physical Examination and History Taking. 6th ed. Philadelphia, Pa: JB Lippincott; 1995.
3. Bates B. A Guide to Clinical Thinking. 6th ed. Philadelphia, Pa: JB Lippincott; 1995.
4. Mollica RF. Traumatic outcomes: the mental health and psychosocial effects of mass violence. In: Leaning J, Briggs SM, Chen L, eds. Humanitarian Emergencies: The Medical and Public Health Response. Cambridge, Mass: Harvard University Press; 1999.
5. Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard trauma questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992;180:111–116.
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