By SAMYUKTA MULLANGI MD, MBA, DANIEL W. BERLAND MD, and SUSAN DORR GOOLD MD, MHSA, MA
Jenny, a woman in her twenties with morbid obesity (not her real name), had already been through multiple visits with specialists, primary care physicians (PCPs), and the emergency department (ED) for unexplained abdominal pain. A plethora of tests could not explain her suffering. Monthly visits with a consistent primary care physician also had little impact on her ED visits or her pain. Some clinicians had broached the diagnosis of functional abdominal pain related to her central adiposity, and recommended weight loss. This suggestion inevitably led her to become defensive and angry.
Though our standard screen for safety at home had been completed long ago, I wanted to probe further, knowing that many patients with obesity, chronic pain and other chronic conditions have suffered an adverse childhood – or adulthood – experience (ACE). Yet, I hesitated. Would a busy primary care setting offer enough latitude for me to ask about a history of trauma when it can occur in so many forms, in so many ways and at different times of life? Furthermore, suppose she did report a history of trauma or adverse experience. What then? Would I be able to help her?
Nonetheless, I began: “Jenny, many patients with symptoms like yours have been abused, either emotionally, physically, or sexually, or neglected in their past. Sometimes they have suffered loss of a loved one, or experienced or witnessed violence. Has anything like this ever happened to you?”
This yielded our first breakthrough. Yes, she had experienced neglect, with parents who were separated for much of her childhood, and then later divorced. She had seen her father physically abuse her mother. With little parental oversight, she had engaged in drug and alcohol use throughout her teenage years. But, she wanted to be sure we understood that this was all behind her. She had gotten an education, was in a committed relationship, and had a stable job as a teacher. That part of her life was thankfully now closed.
But was it? Research demonstrates the incredible prevalence of ACEs and their association with illness and health risk behaviors even much later in life. In a groundbreaking 1998 study, almost two-thirds of close to 10,000 participants reported at least one ACE, and 12% reported having four or more. Compared to participants who reported no ACEs, individuals with 4 or more ACEs were more likely to have severe obesity (Odds ratio (OR)=1.6), depression (OR=4.6), and a previous suicide attempt (OR=12.2). Research also suggests that cumulative ACE exposure matters more than the type of ACE , with the association between multiple ACEs and disease onset following an additive pattern. Not surprisingly, traumatic adult experiences also affect health outcomes. Of particular relevance for Jenny, previous trauma increases the likelihood of unexplained gastrointestinal syndromes(OR = 1.75).
The prevalence of ACEs and their influence on health provides strong rationale for asking about trauma in the adult primary care setting. Primary care treats the whole person, not just one organ system, and these relationships are ideally characterized by care continuity and trust, so patients may feel more comfortable disclosing painful or, in their eyes, shameful experiences, to their PCP. Unlike in the pediatrics setting, however, there appears to be under-recognition and under-treatment of trauma for adult patients.
Inquiring about trauma confronts many challenges in the adult primary care setting, especially a PCP’s extensive care responsibilities in a limited time frame. How might primary care physicians ask about trauma in a way that is sensitive to time demands, yet also open to the many forms and types of trauma? Experts recommend using standardized instruments. Using a form, however, runs the risk that patients may disclose an experience not addressed during the encounter, or that they do not disclose traumatic experience due to lack of human interaction. In our practice, we often use a general question about trauma so patients can answer without specifics, if they prefer: “Many people have experienced some kind of trauma in their lives. That could be living in a war zone, but it could also be growing up with a parent who was abusive or had substance use disorder. It could be experiencing or witnessing violence, or being bullied. Has anything like that ever happened to you?” Then, if indicated, we can follow up with an ACE questionnaire or other modality.
What if patients resent such questions? What if patients perceive their physical symptoms are being minimized? In Jenny’s case, raising the question later in the relationship when some trust had been established may have made her more open to disclose her history. On the other hand, if the question had been posed routinely during her new patient past medical and social history, when we routinely ask about sex and drugs, and she did disclose, this could have greatly informed her treatment, led to better therapy, and avoided unnecessary, expensive and potentially harmful testing.
Like other sensitive topics (death and dying, sex), PCPs, being human, may be uncomfortable having such conversations. However, we suspect that the primary reason why providers are reluctant to ask their patients about their history of trauma is that, once uncovered, they wonder how they can help.
To truly transform into a trauma-informed primary care practice, it is not enough to simply ask about patients’ experiences with trauma. A comprehensive approach invests in trauma training, in the form of employee workgroups, lunch sessions, or coaches. Institutional investments in a robust mental health professional and social work team, particularly if co-located in primary care, can meet some of these patients’ needs. Perhaps providers, would be more likely to probe about a patient’s experience with trauma when they know that they have trained professionals available who can help treat the patient suffering from this history, and that patients can experience improvement.
Ideally, every primary care practice would become and stay trauma-informed through such comprehensive efforts. But absent such organizational change, what can adult primary care practitioners do about adverse experiences’ impact on their patients’ health and well-being? First, ask them. We who frequently and routinely inquire about adverse experiences learn quickly how prevalent such experiences are in patients with eating disorders, pain, chronic diseases like diabetes, and mental illness; in other words, most of our patients. Second, serve as external validation by telling the patient that something bad happened to you, and it is not your fault. Sexual assault experiences in particular, even those experienced by children, often create guilt. Third, let patients know how such experiences can contribute to their obesity, their substance use disorder, or other symptoms and conditions, and how treatment of those conditions requires an understanding of the impact of that experience. Finally, and most obviously, patients with ACEs or post-traumatic stress syndrome, or who have newly divulged a long-withheld story of trauma, need psychotherapy, not psychoactive medications.
Jenny was initially skeptical when we discussed the possibility that her adverse childhood experiences may be impacting her in non-intuitive ways today – her obesity, her abdominal pain. Though initially disbelieving, Jenny did agree to engage in more talk therapy with a social worker. At last check, she had not needed to visit the ED for over four months!
Acknowledgements: We thank Israel Liberzon, MD, Michigan Medicine, Sheila Marcus, MD, Michigan Medicine, Katherine Rosenblum, PhD, IMH-E, University of Michigan, and Marcia Valenstein, MD, MS, Michigan Medicine, for their helpful contributions, for which they received no compensation.
Samyukta Mullangi is a physician at New York-Presbyterian Hospital and health policy researcher at Weill Cornell Medicine, where she studies business model innovation in health care as it relates to the adoption of new technologies.