For years I have worked with patients who have suffered from Post-Traumatic Stress in the aftermath of life-threatening medical illness- be it cancer, heart attack or stroke etc. Particularly in the first few months post-diagnosis and treatment, many have had intrusive dreams and memories associated with the illness, have avoided external reminders or people to whom they might have to reveal or be reminded of the diagnosis, suffered shifts in mood, fear of physical risks, reported cognitive fog, in addition to emotional suffering from feelings of anger, guilt, blame and fear. It is the psychological pain of medical illness.
According to DSM-V a persistence of such symptoms for over three months is diagnosed as Post-Traumatic Stress Disorder (PTSD). Many who have suffered serious life-threatening illness qualify by reason of the persistence of symptoms driven by ongoing treatment, follow-up, and fear of the recurrence at any time on their life journey.
While their PTSD symptoms are comparable to those who have suffered from life-threatening external events as combat, rape or assault, Dr. Donald Edmondson has proposed a new model of PTSD for those who have been traumatized by medical illness.
This model, The Enduring Somatic Threat Model (EST) of Posttraumatic Stress Disorder captures in a more distinct way, the emotional fallout from life-threatening medical events. It may well fit the persistence of symptoms and emotional reactions that COVID-19 survivors are reporting.
The differences between PTSD and the Enduring Somatic Threat Model of PTSD:
- PTSD results from a discrete and external event as rape, assault, or combat. The source of threat is external and has an actual beginning and end.
- Enduring Somatic Threat (EST) results from diagnosis and treatment of a life-threatening illness as Cancer or Heart Attack, etc. The source is an internal, somatic threat that is enduring and without a definite end.
- The occurrence and time perspective of Posttraumatic Stress Disorder (PTSD) for an external trauma is the past, although many feel that they relive aspects of it in the present.
- The occurrence and time perspective of Enduring Somatic Threat (EST) is past, present and future. There is the diagnosis of the illness, the past/present medical intervention and the fear of future recurrence. The vigilance is not to the dangerous road in Iraq or the ride with the stranger– it is to an internal sensation or symptom in one’s body.
According to Edmondson, what maintains the PTSD symptoms in The Enduring Somatic Stress Model is the “ underlying fear of mortality” from medical illness.
The Need for the Enduring Somatic Threat Model of PTSD
As he describes, Edmondson’s work is prompted by the tendency to overlook PTSD and the impact of health consequences of PTSD in patients who have suffered from life threatening medical events. He found in his research that in the case of acute coronary syndrome, for example, patients who developed PTSD due to the event were at double the risk for recurrence and mortality in the next three years compared to those who did not develop PTSD.
Crucial to his proposal and ongoing research of the Enduring Somatic Threat Model ( EST), as a more distinct way of capturing the post-traumatic distress suffered by those with medical illness, is the need to recognize that the symptom clusters, of hypervigilance, hyperarousal, avoidance, cognitive and moods shifts, may present somewhat differently in medical patients and have different implications.
Avoidance of stimuli that are associated with the traumatic event is a key feature of posttraumatic stress disorder (PTSD). There is often an ever increasing attempt to avoid anything that might re-trigger the flashbacks, physical terror, self-blame, etc. of the event. Sadly, this keeps the person from ever integrating the horror – of finding a place for it in their story.
In the case of medically caused PTSD, which we might consider in terms of an EST model, avoidance not only precludes emotional integration of the trauma from hearing the diagnosis to dealing with the illness, it may add the dangerous reality of avoiding medical and medication recommendations.
Implications for Survivors of COVID-19
Wedged between those who have had a very mild case of COVID-19 and the tragic loss of now over 160,000 deaths in the US from this pandemic, are many who have suffered with serious symptoms from COVID-19, only to be faced weeks or even months after recovery with new symptoms and long-term complications from Covid-19.
Given the unknowns and the varied symptoms from extreme fatigue to lung scarring, blood clots, cardiac, and neurocognitive impacts reported as collateral damage from the virus, it would make sense that survivors would be frightened and traumatized. The emotional aspect of this might well fit into an Enduring Somatic Threat Model of PTSD. It might help conceptualize and make meaning of feelings and responses.
It may legitimize hyperarousal, re-experiencing of feelings from different points during the illness, emotional avoidance as well as cognitive and mood swings. Importantly, it may enable seeking support from both medical and mental health providers as well as support groups with others suffering in similar ways. People heal in community. The journey of COVID -19 is a journey into uncharted territory – go with a group.
New formulations like Edmonson’s Enduring Somatic Model of PTSD provide language to talk about what we are feeling and fearing.
They are scientific advances and emotional gifts.