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"Trauma-related symptoms/illnesses"

By: Patricia D. McClendon, MSSW

Date: March 1995

Note: This is a slightly revised bit that I wrote back in March 1995 about significant trauma, PTSD, DDs, somatoform disorder, and "real" physical illnesses to a member of ISSD.

Many trauma survivors meet DSM-IV criteria for PSTD and/or dissociative disorders. Many also are diagnosed as having somatoform conditions which in my mind are conditions like fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, pain disorders, etc., (maybe MS and RA, etc.). It's only normal to have physical symptoms after enduring significant trauma because the trauma, I believe, permanently alters the survivors' neurochemistries. To me, somatic memories or "body memories" are part of our complicated (see Bennett G. Braun's "The BASK model of Dissociation - Part 1 & 2 in the journal DISSOCIATION, March & June 1988, Vol 1. No. 1 & 2) neuropsychophysiologic (NPP) state-dependent memory (SDM)... thus the symptoms "reappear" on anniversary dates, i.e. Halloween, victimization dates, etc. because there are enough environmental cues to stimulated NPP-SDM. I believe the incident of somatoform disorders is around 70-80% in the DID (or MPD) literature ... it would probably be 100% but many doctors aren't good listeners and many patients were discouraged from early childhood from discussing their pains (they did not count). "Long-standing somatic symptoms often reflect deeply dissociated visceral memories of traumas, long-standing interpersonality conflicts, and chronic self-destructive behavior." (Frank W. Putnam, 1989, Diagnosis & Treatment of MPD, p.293). I agree with the first part of the sentence, but since trust is so damaged, mutual loving relationship are difficult for many survivors, then the last part goes like this ... I was a bad little girl (or boy) ... that's why daddy hurt me and the reason I have fibromyalgia is because I am bad and should hurt ... and, if that doesn't cause enough pain, I must inflict it, so I can finally be punished enough for being bad ... then I can have a "good" time until the next time. Or, if I don't have pain today that means something is going to happen to cause me pain ("waiting for the other shoe to drop", so, it is safer to stay in pain).

I would imagine that you would find raging workaholic suffering with fibromyalgia and the like ... because, they can never do enough to erase their badness, so they push their bodies past the limits. Likewise for the chronic fatiguers. I think the hyperviligance of trauma survivors can be emotionally and physically exhausting, they are never safe, never accomplished enough, etc. (Note: Some CFS is now believed to be due to neurally mediated hypotension, NMH, or sudden drops in blood pressure (30 mm Hg) and/or bardycardia decrease of 20/min. Lancet, March 11,1995, 345:623-624). Interestingly, adrenaline isn't discharge to help raise the blood pressure as it should. Has significant trauma disrupted this "fight or flight" system? Where do you run when you are a small child? Maybe shutting it down after a while is an adaptive autonomic response? Many CFS-ers, especially females, report significant childhood trauma. Also, medications that lower blood pressure are contraindicated, i.e., some of the tricyclics (antidepressants).

In an article entitled, "The Dissociative Disorders Interview Schedule: A Structured Interview" by Colin A. Ross, Sharon Heber, + 4 others in DISSOCIATION (Vol.II, No. 3, Sept., 1989, pp. 169-189), 102 subjects (who had received dx of MPD) were given this "interview" ..94.1% MPD, 91.2% Major depressive episode, 63.7% BPD, and 60.8% Somatization disorder. Subjects were asked if they had: headaches, abdominal pain, nausea, back pain, shortness of breath , dizziness, vision problems, paralysis or weak muscles, etc., etc. The "kicker" of this interview is: a) no physical disorder has been found... therefore the subjects get the Somatization dx, a.k.a. "It's all in your head!" That's because the doctors don't recognize fibromyalgia & the like, because they can't quantify it through diagnostic tests, i.e., high WBCs, etc. They just haven't developed the "right" test, yet!

With all that said, good psychotherapy can "alter" the brain's neurochemistry ... desensitize "triggers" and change the a person's way of responding to a trigger, restructure things cognitively, etc. It ain't all in the body, but it sure ain't all in the head!" (It = physical & emotional symptoms).

There are a couple of articles that I downloaded from Compuserve a few months back that you might be interested in:

1- "Comorbidity of fibromyalgia with medical and psychiatric disorders", America Journal of Medicine, April 1992, v92, n4, p363(5), by James Hudson et al.

2- "Posttraumatic stress disorder presenting as fibromyalgia", America Journal of Medicine, May1993, v94, n5, p548(2), Talley F. Culclasure et al.

After re-reading the article that I referred you to: "Post-traumatic stress disorder presenting as fibromyalgia", America Journal of Medicine, May 1993, v94, n5 by Talley F. Culclasure et al, I've got to LOL (laugh out loud) at the authors' biases!!! Well, first let me give them a little credit.. To quote them, "We report the first case of post-traumatic stress disorder (PTSD) presenting as FMS". I will quote from their article, then counterpoint their obvious biases with my obvious bias right after each section of their quoted material.

"Fibromyalgia (FMS) is a common rheumatic disorder predominantly seen in women associated with disturbances of stage 4 sleep [1]. FMS in men is uncommon [1] and should prompt consideration of an underlying cause. We report the first case of post-traumatic stress disorder (PTSD) presenting as FMS."

?@#! All patients presenting with somatized symptoms, i.e., fibromyalgia, chronic fatigue syndrome, chronic pain, etc. should prompt consideration of an underlying cause!

"A 47-year-old man was referred for evaluation of chronic muscle pain and generalized fatigue...7 years as a prisoner of war (POW) ... Physical examination revealed multiple tender points ... Sleep study was declined."

#%@! If a sleep study had been done, this patient probably would have had a disturbance "of stage 4 sleep" just as the women who have FMS do.

"FMS and PTSD were diagnosed. PTSD treatment was recommended to improve sleep, but he declined for fear of employment loss related to the diagnosis ... FMS and PTSD are both often associated with other co-morbid psychiatric disorders, including depression, obsessive-compulsive disorder, panic disorder, phobias, drug abuse/dependence, and alcoholism [6,7]".

*** Depression is a normal response to trauma and should not be stigmatized as a "mental illness". Obsessive-compulsive behavior (i.e., workaholism, gambling, etc. ... anything to distract the mind from the somatized symptoms ... and from the dissociated feelings, sensations, etc.) is adaptive behavior given the only other option is to deal with traumatic experiences in the here and now. Panic disorders and phobias are very effective strategies for avoiding living fully, which would include dealing with traumatic experiences. And, when all else fails, drink or drug to keep the traumatic material at bay. All the above diagnoses can be traumatic driven and as such should not be seen as a sign of "mental illness", but rather as an underlying cause of these symptoms.

" ... Sleep disturbance is believed to be the hallmark of PTSD, with repetitive dreams or flashbacks resulting in dysfunction of REM sleep [3] ... "

#@*+! So, that means to me that ALL patients presenting with "sleep disturbance" be evaluated for PTSD and FMS!

"FMS may be the presenting manifestation in patients with PTSD. The diagnosis of PTSD should be considered in any male patient with symptoms of FMS and a history of extensive combat or captivity."

!#%*@%!!!!!!! FMS may be the presenting manifestation in patients with PTSD. The diagnosis of PTSD should be considered in ANY, ANY patient with symptoms of FMS and a history of significant trauma, whether in childhood (physical, sexual, and/or extreme emotional abuse) or in adulthood (rape, battering, car wrecks, combat in the military).

So, I'd say that you could find you a bunch of Vietnam and Gulf War veterans to do a study on people who present with fibromyalgia, but who have undiagnosed PTSD or dissociative disorders ... (I hope you are laughing by now at my response to the authors bias) but, what I think would be just as interesting is a study of women who have been to their doctors for years presenting with FMS (or CFS, etc.) and PTSD and being told that it is all in their heads!

The authors cited two articles that you might be interested in: [6] "Post-traumatic stress disorder in the general population. Findings of the epidemiologic catchment area study",
N Engl J Med 1987:317:1630-4, J.E. Helzer et al [7] "Psychological status of women with fibromyalgia (FMS) [abstract]. Arthritis Rheum 1990: 33 Suppl: S136.

Regards to you all and do let me hear the results of this "ground-breaking" research in trauma-related illnesses. I'd like the medical establishment to get away from somatization diagnoses, in favor of trauma-related diagnoses.

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Last updated on January 13, 2011.

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