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.