Physical Health Effects of Traumatic Exposure

Paula P. Schnurr, Ph.D.National Center for PTSDExecutive Division, &Dartmouth Medical School

Presentation Goals

To increase understanding that:– trauma is related to poor health– a person’s reaction--PTSD especially--mediates the effect of exposure– there are plausible mechanisms through which PTSD could promote health

Premise: Good clinical practice is informed by research findings

Common Views About How Mental States Affect Health

• “It’s all in your head…”

• “You’re not really sick, it’s just stress…”

• “OK, you’re sick, but it’s only because you’re stressed…”

Example:How Depression (vs. Smoking) Affects Coronary Disease Onset

0

0.5

1

1.5

2

2.5

3

Risk

Smoking (US

Surgeon General)

Passive Smoking

(He et al., 1999)

Depression

(Wulsin et al., 2003)

All p < .05

What Are Health Outcomes?

Influence Due toMental Health Example

Self-reportsSymptoms +++ PILL, SCL-90Global status ++ SF-36Functioning ++ SF-36Conditions + “Has a doctor ever told

you that you have...?”

Utilization + Self-report, database

MorbidityPhysician exam (+) Review of systemsLaboratory tests 0 EKG

Mortality 0 Standardizedmortality ratio

Trauma in Relation to Illness and Injury

Direct– Survivor physically harmed

by trauma– Less common– Health problems related to

trauma– Medical problems part of

survivor identity

Indirect– Survivor not physically

harmed by trauma– More common– Health problems unrelated to

trauma

Findings on Trauma and Poor Health

Self-Report Utilization Morbidity Mortality

Military ++ + +/- +

Sexual ++ ++ +/- NA

Disaster ++ ++ + +/-

Other ++ NA + +

++ = clear association, + = probable association, +/- = inconsistent information, NA = insufficient information

Health Outcomes as a Function of Childhood Trauma

Health Risk Behaviors as a Function of Childhood Trauma

Wartime Stress and Coronary Artery Disease in Civilians (Sibai et al., 1989)

0

2

4

6

>2 war events >1 green-linecrossing/wk

Od

ds

Rat

io

Cases (³70%Stenosis) vs.Visitor Controls

Cases vs.Patient Controls

Cases more likely Cases more likely than controls to than controls to have high exposure have high exposure to war stressorsto war stressors

10-Year Mortality in War-Exposed Civilians (Sibai et al., 2001)

10

20

30

40

50

60

70

0 1-2 3-4 ³ 5

Number of War-Related Events

Rat

e P

er 1

000

Per

son

Yea

rs

Men: CVD

Men: All-Cause

Women:CVD

Women:All-Cause

Questions???

• How does traumatic exposure lead to poor health?

How Does Trauma Lead to Poor Health?The Role of Distress as a Mediator

DistressStressful

Event

PhysicalHealth

Outcome

Trauma PTSD Health

Higher WZE associated with a greater number of medical conditions(adjusted for age and education)

PTSD as a Mediator of the Relationship Between Warzone Exposure and Health in Female Veterans (Wolfe et al., 1994)

# Medical Conditions

WZ Exposure

.42**

PTSD as a Mediator of the Relationship Between Warzone Exposure and Health in Female Veterans (Wolfe et al., 1994)

Effect of WZE declined from .42** to .08 when PTSD added

PTSD Sxs

# MedicalConditions

# MedicalConditions

.42**

.08

WZExposure

WZExposure

Findings on PTSD and Poor Health

Self-Report Utilization Morbidity Mortality

Military ++ + + +

Sexual ++ + + NA

Disaster + + + NA

Other + + + NA

++ = clear association, + = probable association, NA = insufficient information

Odds of Self-Reported Medical Disorder Due to PTSD in Female Vietnam Veterans (Wolfe et al., 1994)

0 1 2 3 4 5

Dermatological*

Gastrointestinal*

Pain*

Gynecological*

Cardiovascular*

Respiratory

Liver

Weight changeOR indicates change associated w/1.0 SD in PTSD symptoms

Adjusted for age, education, and WZE

*p < .05

*

*

*

*

*

Adjusted Odds of Self-Reported Medical Disorder Due to PTSD in Vietnam Veterans (Boscarino, 1997)

0 0.5 1 1.5 2 2.5

Cancer

Circulatory

Digestive

Musculoskeletal

Genitourinary

Endocrine

Nervous system

Skin

Respiratory

Any disorder

*p < .05

*

*

*

*

*

*

SF-36 Scores in Mustard Gas Exposed Veterans (Schnurr et al., 2000)

0 20 40 60 80

PhysicalFunction

Role Impair-Physical

Fatigue

Pain

PTSD and partial PTSD < no PTSD

Full PTSD

PartialPTSDNo PTSD

NormativeSample

Predicted Physical Symptoms, Age 65 Retirement (Schnurr et al., 2005)

0

5

10

15

20

25

51 53 55 57 59 61 63 65 67 69 71 73 75 77 79

Noexposure

Traumaonly

PTSD

Adjusted Annual Cost Ratios in Female HMO Enrollees (Walker et al., 2003)

0

0.5

1

1.5

2

2.5

PC Specialty MH Total

Low v. Medium PTSD

Low v. High PTSD

PCL med = 30-44,high = 45+

*p < .05 adjusted for demographics, chronic disease, and mental health

**

*

*

PTSD and Hazard of Physician-Diagnosed Disease in Older Veterans (Schnurr, Spiro, & Paris, 2000)

0 0.2 0.4 0.6 0.8 1 1.2 1.4

Cancer

Endocrine

Hypertension

Ischemic

Other Cardio.

Arterial

Pulmonary

Upper GI

Lower GI

Urinary

Dermatologic

Musculoskeletal

Hazard is expressed per 10-pt increase in PTSD sxs and is adjusted for age, BMI, smoking, and alcohol consumption

*p < .05

*

*

*

*

PTSD and Arterial Disorder in Older Veterans (Schnurr et al., 2000)

Odds of Physician-Diagnosed Disorder as a Function of PTSD Diagnosis (Ouimette et al., 2004)

0

0.5

1

1.5

2

2.5

3

3.5

4

Odds Ratio

Circulatory

Musculosketal

Gastrointestinal

Dermatological

**

Gender did not moderate the effects of PTSD

*p < .05, adjusted for age, smoking, alcohol, BMI

Mortality Due to PTSD in Vietnam Veterans (Bullman & Kang, 1994)

0

0.5

1

1.5

2

2.5

All Causes Cancer Circulatory Digestive ExternalCauses

RR

**

*p < .05

Questions???

• How does traumatic exposure lead to poor health?

• Are the effects of PTSD unique from the effects of other psychiatric disorders?

Effects of PTSD and Depression on SF-36 Physical Component Scores in Female Veterans (Frayne et al., 2004)

-7

-6

-5

-4

-3

-2

-1

0

Depressionalone

PTSD alone

PTSD andDepression

Odds of Cardiovascular Problems in Vietnam Veterans with PTSD (Boscarino & Chang, 1999)

0 1 2 3 4 5 6 7

Any ECG Abnornmality

Infarction

AVC Defect

Arrhythmias

VC Defect

ST/T Abnormality

Odds Ratio

PTSD

PTSD adj. for anxiety &depression

*

*

**

*

N = 4,462

Adjusted for demographic, military, and health risk covariates. *p < .05

Medical Service Utilization in Male Vietnam Veterans (Schnurr et al., 2000)

0

0.5

1

1.5

2

2.5

3

3.5

Od

ds

Rati

o

Recentoutpatient

Recentinpatient

Recent VAoutpatient

LifetimeVA

outpatient

LifetimeVA

inpatient

PTSDOther Axis ISubstance Abuse

**

* *

*

*

**

*p < .05

• How does traumatic exposure lead to poor health?

• Are the effects of PTSD unique from the effects of other psychiatric disorders?

• How does PTSD lead to poor health?

Questions???

Case-Control Study of High v. Low VA Healthcare Users(Deykin et al., 2001)

PTSD

Depression

MedicalConditions

Utilization

Effects of PTSD on number of medical conditions both direct

and mediated through depression

OR of PTSD in High v. Low

Users = 2.17

Effects of PTSD and Depression on Health Status in Peacekeepers(Asmundson et al., 2002)

*p < .01

PTSD

Depression

PoorHealth

AlcoholAlcoholUseUse

.24*

.81* .40*

.17*

Possible Ways PTSD Could Affect Health

PsychologicalDepression

HostilityCoping

BehavioralSmoking

DietExercise

BiologicalCardiovascular reactivityAutonomic hyperarousal

Disturbed sleep physiologyAdrenergic dysregulation

Enhanced thyroid functionAltered HPA a ctivity

Dynamic Regulation of Body Systems

• Homeostasis: body maintains constancy within a tight range (e.g., Cannon, 1929)

• Allostasis: body increases or decreases vital functions within an operating range, in response to environmental challenge (Sterling & Eyer, 1988)

A Unifying Mechanism: Allostatic Load

• “The strain on the body produced by repeated up and downs of physiologic response, as well as the elevated activity of physiologic systems under challenge, and the changes in metabolism and wear and tear on a number of organs and tissues”

– McEwen & Stellar, 1993

Allostasis and Allostatic Load

Allostatic Load

Allostasis

Effect of Allostatic Load on Incidence of Cardiovascular Disease (Seeman et al., 1997)

New Disease Over 2.5 Years (N = 736)

0%

5%

10%

15%

Allostatic Load Category

0

1-2

≥ 3

PTSD and Allostatic Load (Schnurr & Jankowski, 1999)

other risk factors

sympatheticactivation

self-medication(smoking & drinking)

stress due to drinkingconsequences

Allostatic Load

Thresholdfor illness

Multifactorial Model of Trauma, PTSD, & Health (Schnurr & Green, 2004)

PTSD

Exposure

BiologicalAlterations

PsychologicalAlterations

AttentionalProcesses

Health RiskBehaviors

IllnessBehavior

Disease

(1) Exposure affects health primarily through PTSD and other distress reactions

PTSD

Exposure

BiologicalAlterations

PsychologicalAlterations

AttentionalProcesses

Health RiskBehaviors

IllnessBehavior

Disease

(2) PTSD and distress reactions affect illness behavior by altering symptom perception

PTSD

Exposure

BiologicalAlterations

PsychologicalAlterations

AttentionalProcesses

Health RiskBehaviors

IllnessBehavior

Disease

(3) Effects of PTSD on disease are mediated through interdependent psychological, biological, and behavioral mechanisms

PTSD

Exposure

BiologicalAlterations

PsychologicalAlterations

AttentionalProcesses

Health RiskBehaviors

IllnessBehavior

Disease

Summary

• Traumatic exposure is related to poor health

• A person’s reaction–PTSD especially–mediates the effect of exposure

• There are plausible mechanisms through which PTSD could promote poor health

Treatment Issues: Two Scenarios

Trauma problems in medical patients

Medical problems in trauma patients

In either case, MH providers need to

address medical problems & work with

medical staff