Letters to the Editor
Treatment of Post-traumatic Stress Disorder Can Be Complex
to the editor: The article by Dr. Grinage, "Diagnosis and Management of Post-traumatic Stress Disorder,"1 continues an excellent tradition in American Family Physician of covering this important and complex disorder. However, we are concerned that many review articles on post-traumatic stress disorder (PTSD) in primary care-oriented journals place too much emphasis on short-term management of the immediate and most distressing symptoms, often heavily emphasizing psychopharmacologic treatment. We appreciate Dr. Grinage's thorough and balanced review,1 which included a broader consideration of most aspects of PTSD. We would like to encourage a greater emphasis on a number of these aspects.
First, an emphasis on pharmacologic treatment of distressing symptoms neglects the fact that recovery from trauma requires healing on an emotional, social, and spiritual level. As noted in the article,1 recovery with multimodal treatment averages 34 months. Further, the family physician is likely to see such patients long after the traumatic event has occurred. The family physician can provide symptom relief through medication, but the absence of the most obvious symptoms does not represent recovery.
Second, exposure to trauma results in a broad spectrum of reactions and clinical manifestations. Many patients presenting to the family physician's office who have been exposed to traumatic events may present symptoms that are diagnostically subthreshold. A well-established body of research indicates that persons exposed to such events as the September 11 attacks, the Oklahoma City bombing, and natural disasters suffer disruption in their lives, increased levels of depression, higher rates of divorce, and increases in alcohol abuse in the years following the event. Not all traumatized patients will meet the diagnostic criteria, but their tragedies and trauma will bring them to their family physician.
Because of the complexity of post-traumatic reactions, it must be consistently emphasized that this disorder responds best to multidisciplinary, multimodal, multiphasic, and coordinated treatment. Further, recovery is associated with social support. Dr. Grinage notes that family therapy may be helpful and that social support has been found to be associated with recovery.1 The family physician is not, and should not be, alone in treating trauma survivors.
There are two types of reactions to trauma. Type 1 trauma reactions are associated with a discrete, relatively recent event. Type 2 trauma reactions are characterized by repeated or extended trauma over the lifespan, and typically are experienced by persons with a history of abuse in destructive families. Although most review articles concentrate on Type 1 reactions, physicians are encouraged to differentiate between Type 1 and Type 2 PTSD. Readers should be aware that the dynamics of these two types manifest in quite different ways.
Reference
1. Grinage BD. Diagnosis and management of post-traumatic stress disorder. Am Fam Physician 2003;68:2401-8.
AFP Policy on Using Generic and Brand Names for Drugs
to the editor: Could you please resume using the commonly used proprietary name in parentheses after the generic whenever possible? I do not always remember the generic name of a medication, often because so many of the drugs in a medication class have similar sounding names. This would save me time when reading American Family Physician (AFP), help me understand what I am reading without having to look up the name in the Physicians' Desk Reference, and reduce confusion about which medication is being referred to in the article. I understand there may be some idealogic reason for not using the proprietary name, but it is often the name most commonly used when discussing the medication. Please give this every consideration. I know many of my colleagues feel the same way.
editor's note: At American Family Physician, our policy on the use of drug names is to use the generic name throughout the discussion, but provide the trade/brand name in parentheses at the first mention. This policy is a compromise between the scientific (purist) approach of always using the generic name, and using the brand name throughout the entire article. The latter is problematic for several reasons: (1) this practice might seem too promotional; (2) some generic drugs have more than one brand name during the initial patent period (for example, Bactrim and Septra, Adalat and Procardia, and Calan and Isoptin); and (3) after the patent period, many generic drugs are sold under multiple brand names.
Learning Deficits May Account for Cases of School Phobia
to the editor: I enjoyed the article "School Refusal in Children and Adolescents,"1 by Dr. Fremont in the October 15, 2003 issue of American Family Physician. School refusal is an important issue, and I would like to add a few observations and recommendations.
In my practice, I have noticed more and more cases of school refusal. In my experience as a family physician and as a parent of a child with this condition, I think that the anxiety and depression described by Dr. Fremont1 often is more related to school than the problems at home or endogenous psychologic issues.
Statistics from the U.S. Department of Education suggest that up to 40 percent of children in the United States do not read at their current grade level.2-4 Most of these children are of normal intelligence. These difficulties often are not identified for several years, by which time issues such as behavior problems, severe academic problems, or school phobia have become more problematic. When kids cannot read at their grade level, their academic and/or behavior performances deteriorate. Often, the cause of these problems is not properly identified as reading and learning problems and these kids are labeled as having behavioral or psychologic issues.
Budgets at the federal, state, and local levels are being stretched. In my experience, early evaluation and intervention of reading and learning problems are seriously delayed and often are not identified until major behavioral or emotional issues become the dominant focus for the child. Schools do not have the money, resources, or staff to properly evaluate many of these children.
Although Dr. Fremont1 suggests psychoeducational and other educational evaluations, it was my impression that the major focus of the article suggested that the origin of school phobia is a primary psychologic problem. I disagree. In dealing with many children who have school phobia, I can think of few who did not have a primary learning or reading deficit that had not been properly evaluated or addressed as the primary cause of their school phobia.
Certainly, concomitant psychologic and home issues are significant contributing factors, but I would urge the author and other clinicians who see children with school phobia to consider reading or learning issues first. The psychologic issues that physicians identify and diagnose may be secondary. Unless reading and learning issues are addressed, any other therapy is doomed to failure.
References
1. Fremont WP. School refusal in children and adolescents. Am Fam Physician 2003;68:1555-60.
2. Children of the code. Accessed online June 11, 2004, at: http://www.childrenofthecode.org/cotcintro.htm.
3. National Center for Education Statistics. State results for the NAEP 2003 reading assessment. Accessed online June 11, 2004, at: http://nces.ed.gov/nationsreportcard/reading/results2003/stateresults.asp.
4. Paige R. Educating a new generation. Speech before the Los Angeles World Affairs Council on February 13, 2002. Accessed online June 11, 2004, at: http://www.lawac.org/speech/paige.htm.
editor's note: This letter was sent to the authors of "School Refusal in Children and Adolescents," who declined to reply.
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