Bernard P. Chang
In the aftermath of life-threatening events, such as heart attacks or strokes, many survivors are consumed by protracted medical evaluations, treatment regimens and lifestyle changes—all with the intention of reducing disease progression or the appearance of future medical events related to the initial bodily threat. The massive medical complex underlying our modern healthcare system has been primed to play the role of heroic healer. Over the past century, medicine and surgery have boasted of dazzling developments—from the creation of miniature sized clot busters for heart attacks, to multi-staged surgeries to repair and replace organs following a devastating injury. Modern medicine has succeeded in offering many patients the opportunity to survive and recover from acute illnesses. Yet in the setting of these impressive medical achievements, emerging work has begun to focus on the psychological sequelae stemming from surviving such illness.
A life-threatening event may represent a fundamental assault on one’s self-being, changing the framework by which we view our body in relation to ourselves. After a catastrophic event such as a debilitating stroke, patients may come to view their bodies—formerly understood as part of an inalienable union with the mind—with new distrust. The body becomes an agent of current misfortune. How patients come to view their survival of such acute events affects not only their psychological well-being, but may in turn also influence subsequent behaviors and physiological processes that can increase their risk for disease recurrence. What are different approaches to confronting the threat to one’s mortality? Might there be both adaptive and maladaptive ways of adjusting? These are the questions that sit at the intersection of cognition and acute care medicine.
“Sickness, insanity and death were the angels that surrounded my cradle and they have followed me throughout my life.” Edvard Munch’s words echo across time to patients sitting in the crowded halls of an emergency room or outpatient clinic. Clinicians classify and describe diseases by their pathophysiology, prognosis, and treatment outcomes, concerns that patients share regarding the treatment and prognosis of their disease. And yet, for many patients, beyond the tangible calculus of treatment success lies a more basic sentiment: my body has in some degree failed me. In the days and months following an acute medical illness, patients often confront the disturbing notion that their bodies may falter again—a notion that can sometimes traumatize patients.
Posttraumatic stress disorder (PTSD) is a psychiatric condition often seen in survivors of external threats, such as war or sexual trauma.(1) Marked by a sense of elevated vigilance and avoidance of reminders of the traumatic event, PTSD is associated with multiple negative psychological and medical outcomes, including substance abuse, depression, and even increased overall mortality.(2) While PTSD symptoms initially appeared to depend on external traumatic events, new research suggests that for some individuals, the survival of an acute life-threatening event may serve as a traumatic trigger. A meta-analytic review by Edmondson and colleagues found that nearly 1 in 8 survivors of an acute cardiac event go onto to have PTSD after surviving the event.(3) This number is even higher for survivors of stroke, with nearly 1 in 4 patients endorsing PTSD symptoms following their stroke.(4) The implications of these studies are significant: following an acute medical event, the threat is not some external force or figure, but rather our own being and bodies. Furthermore, it appears that the subjective perception of threat, rather than the ultimate medical diagnosis itself, is the most important factor driving the development of PTSD in these individuals. A recent study of patients presenting to the emergency department for possible heart attack found that rates of PTSD were associated with a patient’s subjective perception of threat; in fact, rates of PTSD were similar among individuals ultimately determined to have a non-cardiac event, compared to patients who had actual cardiac events.(5) That is to say, irrespective of the final medical diagnosis, a significant driver of PTSD in these patients was their impression of how serious the threat was.
What does this work mean for clinicians and patients? From one standpoint, the lack of evidence for having suffered a true medical event may be reassuring and positive. But by focusing exclusively on the physiologic nature of disease, clinicians and patients alike may fail to consider how the interpretation of disease shapes the totality of the individual experience—including the potential for trauma. By considering the patient narrative along with clinical data and provider interpretation, we arrive at a more nuanced approach to caring for not just the physical manifestation of disease, but also the psychological toll that often accompanies it. Making the effort to understand the narrative of the individual’s personal confrontation with perceived disease may unveil novel insights into the healing process. This awareness of the intimate connections between our bodies and the way we perceive our mortality will have far-reaching clinical consequences.
Bernard P. Chang is an attending physician on faculty at Columbia University Medical Center with a research focus on psychological outcomes following acute medical illness. He received his MD from Stanford and his PhD in experimental psychology at Harvard, where he also completed his residency training in Emergency Medicine.
 Weathers F, Litz B, Keane T, Palmieri P, Marx B, P. S. The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD. http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp. Last accessed September 26/2016.
 Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): Development and initial psychometric evaluation. Journal of Traumatic Stress. 2015;28:489-98.
 Edmondson D, Rieckmann N, Shaffer JA, et al. Posttraumatic stress due to an acute coronary syndrome increases risk of 42-month major adverse cardiac events and all-cause mortality. Journal of psychiatric research. 2011;45:1621-6.
 Wang X, Chung MC, Hyland ME, Bahkeit M. Posttraumatic stress disorder and psychiatric co-morbidity following stroke: the role of alexithymia. Psychiatry research. 2011;188:51-7.
 Chang BP, Sumner JA, Haerizadeh M, Carter E, Edmondson D. Perceived clinician-patient communication in the emergency department and subsequent post-traumatic stress symptoms in patients evaluated for acute coronary syndrome. Emergency medicine journal : EMJ. 2016;33:626-31.