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Social, Cultural, and Clinical Dimensions of Traumatic Experiences of Primary Care Patients
Arch Fam Med. 2000;9:812-813.
THE ARTICLE by Holman et al1 provides further evidence of the disturbing reality that a majority of individuals in the United States experience a traumatic event at some point in their lifetime. Moreover, while previous studies have documented a clear dose-response relationship between such events and the risk of posttraumatic stress disorder,2 this study demonstrates that victims of traumatic experiences are also more likely to have a psychiatric disorder other than posttraumatic stress disorder.
While no one is immune to the likelihood of experiencing a traumatic event, some segments of our society are at greater risk for such experiences, as well as for the development of trauma-related psychiatric disorders. These segments have traditionally been categorized as being of low socioeconomic status,3-4 nonwhite minorities,5-6 and refugees fleeing ethnic strife, civil or international conflicts, and political or religious persecution.7-8 These segments are also less likely to have a regular source of primary care because of a lack of adequate health insurance or access to health services.9
The reasons for this increased vulnerability, however, remain poorly understood. One of the classic debates surrounding the causes of psychiatric disorders among low-income patients has been the direction of causality in this relationship (ie, social selection vs causation).10 For some, the disability associated with psychiatric disorders often results in unemployment and loss of income, or exclusion from the community. Hence, these individuals have low social and economic standing or become immigrants by virtue of their disorder. For others, being of low socioeconomic status and/or an immigrant adds to the risk of experiencing a psychiatric disorder subsequent to a traumatic experience. These individuals often live in threatening situations and lack the material and social resources to shield themselves from traumatic experiences or to successfully cope with their aftermath. The traumatic experience is further complicated by other stressors related to poverty, hazardous occupational and residential environments, and acculturation.
Holman and colleagues do little to resolve this debate because their cross-sectional design does not enable us to identify the direction of causality in this sample of primary care patients. Nevertheless, their study clearly reveals the effect of this association on the delivery of primary care to these segments of the population. Although the prevalence of lifetime (57%) and past-year (10%) traumatic experiences is consistent with that observed in more representative samples of the general population,2, 6 the rates of lifetime and past-year psychiatric disorder are much higher than those reported in other studies of primary care patients.11-12 In other words, the increased risk of developing a psychiatric disorder subsequent to a traumatic event may be more relevant here than the event itself.
Furthermore, the results of this study show that not all immigrant and other low-income patients are alike with respect to the experience of trauma or trauma-related psychiatric disorders. With the exception of slightly higher rates of domestic violence, Mexican immigrants in this study appear to have experienced fewer traumatic events than immigrants from Central America. With the exception of higher rates of war-related violence and other traumatic experiences, Latino immigrants reported fewer experiences with interpersonal violence than US-born Latinos. With minor variations, US-born Latinos and non-Latinos experience similar levels of interpersonal violence. The experience of trauma also changes throughout time. Immigrants from Central America are significantly more likely to have experienced a traumatic experience in their lifetime than US-born whites. However, while not significantly different, they are less than half as likely to have experienced a recent traumatic event. In each instance, location, reflected either in terms of place of origin or current residence, seems to exert a stronger influence than ethnicity on the risk of experiencing a traumatic event, while socioeconomic status, reflected primarily in terms of employment status, seems to exert a stronger influence than ethnicity on the risk of experiencing a psychiatric disorder that is independent of a traumatic event. The differences in the experience of traumatic events and the vulnerability to trauma-related psychiatric disorders lend support to the argument that these disorders model and articulate broader social phenomena, serving as metaphors for one another.13-14
Both the scope of the problem and the differences exhibited between patients presumed to be at risk by virtue of their immigrant or socioeconomic status dictate a need for family physicians and other primary care providers to screen low-income patients for trauma-related psychiatric disorders. Such patients are more likely to understand and express their disorders in somatic terms and, in combination with the stigma often attached to the concept of "mental" illness and limited access to health care, thereby more likely to seek relief for their illness by visiting a primary care provider rather than a mental health specialist.15 A primary care physician's lack of understanding of the patient's explanatory model, especially that of immigrant patients, language, or culturally and socially influenced patterns of symptom expression, make the task of accurately diagnosing the problem and implementing an effective solution somewhat problematic.16 The treatment of even seemingly manageable health problems like high blood pressure, diabetes, asthma, or otitis media, becomes quite complicated when the likelihood of compliance with treatment regimens is threatened by the neuropsychiatric deficits associated with posttraumatic stress disorder.17-18
However, increased screening of low-income, medically underserved primary care patients for trauma-related psychiatric disorders is only part of the solution. A certain level of cultural competency is required for the diagnosis and treatment of trauma-related psychiatric disorders and other illnesses in these patients, especially those who are immigrants to the United States. This competency includes the application of culturally appropriate screening and diagnostic instruments and protocols, the understanding of patient explanatory models, and the use of negotiation skills to address both explanatory models and management options.19-20 Most importantly, culturally competent delivery of health care to these patients requires an understanding of the larger social context in which traumatic experiences and vulnerability to psychiatric disorders subsequent to these experiences occur. Without such an understanding, these disorders will remain undetected and untreated.
Lawrence A. Palinkas, PhD
Immigrant/Refugee Health Studies Program
Department of Family and Preventive Medicine
University of California, San Diego
La Jolla, CA 92093-0807
REFERENCES
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1. Holman EA, Silver RC, Waitzkin H. Traumatic life events in primary care patients: a study in an ethnically diverse sample. Arch Fam Med. 2000;9:802-810.
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RELATED ARTICLE
Traumatic Life Events in Primary Care Patients: A Study in an Ethnically Diverse Sample
E. Alison Holman, Roxane Cohen Silver, and Howard Waitzkin
Arch Fam Med. 2000;9(9):802-810.
ABSTRACT
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