When a trauma survivor repeatedly relives the trauma and experiences constant anxiety, hypervigilance, and trouble sleeping, she may have post-traumatic stress disorder (PTSD), which has been linked to an increased risk of death from cardiovascular disease (CVD) in men.
Just as PTSD Awareness Month draws to a close, new findings have emerged linking PTSD with cardivascular disease risk in women, as well. The study, published June 29 in Circulation, found 60 percent higher rates of heart attacks and strokes among women with a history of trauma who also had four or more PTSD symptoms, compared to women who reported no trauma exposure. Women with a history of traumatic events who reported zero PTSD symptoms had 45 percent higher rates of heart attacks and strokes, but women with a trauma history and one to three symptoms had no elevated risk. Only about 21 percent of the participants reported having had no trauma exposure.
These results reinforce the mind-body link between conditions often considered separately as psychological and physical, says author Jennifer Sumner, PhD, a clinical psychologist at Columbia University Mailman School of Public Health in New York City. “Our findings suggest that PTSD really is not exclusively a psychological problem but one that also includes chronic disease,” Dr. Sumner says. Studies already have shown that cardiovascular eventscan themselves be a risk for PTSD.
PTSD is twice as common in women as in men. In their work, Sumner and her co-authors focused on a population of 49,978 women in the Nurses’ Health Study II. Study participants completed a questionnaire that assessed their recall of exposure to any of 15 traumatic events, including natural disasters, unwanted sexual contact, and physical assault, and a seven-item screening tool for PTSD symptoms. A score of four or more on the PTSD screening serves as an indicator of probable PTSD, according to the study authors. At the time they completed the PTSD screen, all of the women were under age 65.
As part of the Nurses’ Health Study II, which began in 1989, participants undergo evaluation every two years. Sumner and her co-authors also took cardiovascular data from these evaluations, covering two decades up to 2008.
“Their results are consistent with previous work, which is great,” says Atif Kukaswadia, PhD, a Toronto, Ontario, mental health epidemiologist. “It’s such an old, established dataset that there aren’t going to be any significant issues.” Dr. Kukaswadia does note the finding of no elevated cardiovascular disease risk for women with a trauma history and one to three PTSD symptoms. One potential explanation, he says, is that the specific type of event — a natural disaster versus unwarranted sexual advances, for example — might be an important factor. The authors probably didn’t have sufficient numbers to look at this possibility, Kukaswadia says in an email, “but this might be why they didn’t see anything in their ‘medium’ group of number of PTSD symptoms.”
That finding was “somewhat surprising to us,” Sumner says, because they were anticipating more of a “dose response” of increasing heart attack and stroke risk with the PTSD symptom number. “The groups currently are small and the cohort is still young, with the cases of CVD still being in the early phases,” she notes. “We are continuing to get data from these women to see if the pattern changes or if with more cases there will be an ability to detect a relationship.”
Rachel Yehuda, PhD, professor of psychiatry and neuroscience, at Icahn School of Medicine at Mount Sinai Hospital in New York City, says that a woman’s coping strategy could play a role in the fact that she reported no PTSD symptoms following trauma. Calling the findings “enormously interesting,” Dr. Yehuda notes that it is rare for people to say that they have no symptoms at all following trauma. “I think that they truly believe it,” she says, “but I feel like an incredible amount of energy might be spent in saying, ‘I’m fine,’” leading to the physical rather than the emotional manifestations of stress. But that’s all speculative, she says. “We have a lot to learn about the different ways that people process the effect of trauma and whether people express them as psychological symptoms or not.”
Sumner says that she and her co-authors also discussed the possibility that women who have experienced trauma but report no PTSD symptoms might be engaging in unhealthy coping strategies, such as cigarette smoking. Indeed, she says, the aftermath of trauma might manifest in physical disease in a couple of ways, including as the outcome of health behaviors like smoking or alcohol use, which are themselves risk factors for heart disease and stroke.
The other possible link is a change in the stress response, including the autonomic, or fight-or-flight, part of the nervous system. The key PTSD features of hypervigilance and being easily startled are signs of a hyperactive autonomic nervous system, Sumner says. The result could be increased heart rate and other consequences for cardiac health.
What about women who aren’t in the Nurses II study who have a history of trauma? If a PTSD screening suggests symptoms, “I would suggest following up with a diagnostic interview, which is the gold standard,” says Sumner, “to discuss to what extent you are bothered by these symptoms and if they are interfering with your life in meaningful ways.”