For HCP: Finding the Missing Link: Don’t Give Up on Repeat-Visit Patients

You glance at your diary and see a familiar name. Your mood shifts—another heartsink patient.[1] You long for a new perspective that can end this vicious cycle.

It’s natural to get frustrated when repeated consultations with the same patient don’t make any headway. Once you’ve exhausted your treatment options, you start to question why these patients continue to return. These dreaded conversations chip away at your empathy, making maintaining a positive bedside manner increasingly challenging.

As a trained healthcare professional, being unable to help these ever-returning patients is affecting your self-confidence, leaving a sense of inadequacy. With every interaction draining your energy, you may not even recognize yourself anymore.

It’s not hard to admit that your current approach simply isn’t working for such patients. Deep down, you know their illness may have psychological origins; however, you hesitate to go down this proverbial road. You haven’t been trained for this type of care and anticipate that it will require time and patience, both of which are lacking. Yet, avoiding them may only lead to more unnecessary consultations in the long-term, spiralling into greater frustration and dissatisfaction for everyone involved.

Have you considered that the source of a patient’s chronic illness could be unresolved trauma? This is one of the concepts of trauma-informed care (TIC), and although it is likely not the solution in every case, revealing a trauma co-morbidity when traditional treatments are failing could offer hope for you and your patients.

To be trauma-informed at its core means realizing the widespread impact of trauma, understanding potential paths for recovery, recognizing the signs and symptoms of trauma, and seeking to prevent re-traumatization actively.[2]

Many people think of trauma and stress as one and the same, but this couldn’t be further from the truth. Stress is a temporary anxiety-like reaction associated with life’s ups and downs; whereas trauma occurs when an event is perceived as intensely harmful (physically or emotionally) with no immediate escape and has lasting effects.

A stress reaction is an early warning system that protects us from real or perceived threats, as follows:[3,13]

1. The primitive unconscious amygdala “sounds the alarm,” immediately triggering the autonomic nervous system as part of a “fight or flight” response.

   
   

2. This warning is sent to other brain areas simultaneously, reaching the hippocampus milliseconds before the medial prefrontal cortex (MPFC).

   
   

3. The hippocampus compares this ‘threatening’ situation with past experiences and nudges the MPFC into action.

   
   

4. Now that it has context, the conscious MPFC takes the information and either immediately calms the amygdala or engages the sympathetic panic reaction.

   
   

5. Through repeated logical decisions and appropriate responses, the MPFC restores balance and normality.

In contrast, fear, horror, or helplessness experienced during traumatic events rewire the brain, bypassing the MPFC and leaving the primal amygdala in control.[4] This drives a relentless sympathetic response that may have lasting effects long after the danger has passed.

Unfortunately, trauma is more common than you might think. Approximately 70% of people, globally, experience at least one traumatic event in their lifetime.[5] While many recover, some experience long-term mental and physical health consequences that may not surface for several years.[6]

Eventually, this sympathetic overdrive and resultant flood of stress hormones, such as adrenaline and cortisol, can trigger inflammatory cascades and manifest physically.[7,8] Additionally, unhealthy coping behaviors (smoking and alcohol consumption) associated with systemic disease are common after trauma.[9]

These delayed trauma effects may explain the chronic symptoms in your heartsink patients, including:[4,6,9]

• Severe obesity

• Sleep disturbances and/or nightmares

• Somatization (e.g., increased focus on and worry about body aches and pains)

• Appetite and digestive changes

• Lowered resistance to colds and infection

• Persistent fatigue

• Elevated cortisol levels

• Hyperarousal (abnormal physiological and psychological responsiveness to stimuli)

• Other long-term health effects, for example, heart, liver, autoimmune, and chronic obstructive pulmonary disease

Understanding this potential link between trauma and chronic disease shifts the focus away from a traditional diagnostic approach and asks, “What happened to you?” rather than, “What’s wrong with you?”[10]

Taking this approach might reveal the root cause of your heartsink patient’s unresolved illness, open a new treatment path, and, ultimately, provide hope. In return, fewer future appointments could reduce frustration and restore confidence in your ability to deliver high-quality care. Even without an obvious link, listening and showing empathy helps; feeling safe, seen, and heard greatly improves patients’ self-reported health scores.[11,12]

Next time you can’t figure out what’s causing a patient’s return visits, consider trauma as part of your diagnostic approach. Learn more about this trauma connection in this article link.

References

1. Reme SE. Medically unexplained symptoms explained. The Lancet. 2024;403(10444):2568-2569. doi:10.1016/S0140-6736(24)01138-3

   
   

2. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.

   
   

3. Feriante J, Sharma NP. Acute and Chronic Mental Health Trauma. In: StatPearls. StatPearls Publishing; 2024. Accessed September 25, 2024. http://www.ncbi.nlm.nih.gov/books/NBK594231/

   
   

4. Treatment (US) C for SA. Understanding the Impact of Trauma. In: Trauma-Informed Care in Behavioral Health Services. Substance Abuse and Mental Health Services Administration (US); 2014. Accessed June 23, 2024. https://www.ncbi.nlm.nih.gov/books/NBK207191/

   
   

5. Post-traumatic stress disorder. Accessed September 3, 2024. https://www.who.int/news-room/fact-sheets/detail/post-traumatic-stress-disorder

   
   

6. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258. doi:10.1016/S0749-3797(98)00017-8

   
   

7. Chu B, Marwaha K, Sanvictores T, Awosika AO, Ayers D. Physiology, Stress Reaction. In: StatPearls. StatPearls Publishing; 2024. Accessed September 25, 2024. http://www.ncbi.nlm.nih.gov/books/NBK541120/

   
   

8. Won E, Kim YK. Stress, the Autonomic Nervous System, and the Immune-kynurenine Pathway in the Etiology of Depression. Curr Neuropharmacol. 2016;14(7):665-673. doi:10.2174/1570159X14666151208113006

   
   

9. Scott KM, Koenen KC, Aguilar-Gaxiola S, et al. Associations between Lifetime Traumatic Events and Subsequent Chronic Physical Conditions: A Cross-National, Cross-Sectional Study. PLOS ONE. 2013;8(11):e80573. doi:10.1371/journal.pone.0080573

   
   

10. Sweeney A, Filson B, Kennedy A, Collinson L, Gillard S. A paradigm shift: relationships in trauma-informed mental health services. Bjpsych Adv. 2018;24(5):319-333. doi:10.1192/bja.2018.29

    
    

11. Rathert C, Mittler JN, Vogus TJ, Lee YSH. Better outcomes through patient - provider therapeutic connections? An exploratory study of proposed mediating variables. Soc Sci Med 1982. 2023;338:116290. doi:10.1016/j.socscimed.2023.116290

    
    

12. Rathert C, Simmons DR, Mittler JN, Enard K, Brooks JV. Good therapeutic connections and patient psychological safety: A qualitative survey study. Health Care Manage Rev. 2024;49(4):263-271. doi:10.1097/HMR.0000000000000412

    
    

13. van der Kolk, B. The Body Keeps the Score. 2014