PTSD and the Homeless: Shell-Shocked on Your Streets

You're working your way through your many patients one day, and this is what you encounter:

• A woman who won't meet your gaze when you ask her questions.
• A man who rocks on the end of the exam table, arms crossed over his chest, eyes unfocused, even as he denies hearing voices.
• Another woman who says she's not using heroin, but whose drifting gaze makes you want to snap your fingers in front of her face to get her to focus.

Nearby, you hear another provider leaving an exam room in disgust, saying, "What can you do if they just won't listen? I can't care more about their problem than the patient does, now can I?"

It's just another typical day on an urgent care shift at a homeless clinic. All of the patients described here are showing tangible symptoms of complex PTSD.

Many of us know a bit about post-traumatic stress disorder, or PTSD, a constellation of symptoms that can arise after a severe trauma, like a car crash, a fire, or a rape. But few of us - not even medical providers who see it day in and day out - know very much about complex PTSD, or disorders of extreme stress, not otherwise specified (DESNOS).In older, quainter-seeming times, it was sometimes called shellshock.

I saw it in Haiti, where friends brought a woman to the aid tent and told me, in horror, that she wouldn't drink water. When I gently pointed out that refusing to drink water would inevitably kill her, the woman would only nod, eyes averted, arms crossed. She could not have been more distant, more dulled, more, well, bored seeming.

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Disclaimer: Identifiable patients mentioned in this post were not served by R. Jan Gurley in her capacity as a physician at the San Francisco Department of Public Health, nor were they encountered through her position there. The views and opinions expressed by R. Jan Gurley are her own and do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.