Research in Context

What is the Relation Between PTSD and Medical Conditions?

Although the relation between posttraumatic stress disorder and inflammation remains unclear, it is evident that many people with PTSD have medical conditions that may be affected by their PTSD symptoms.

Fed Pract. 2018 September;35(9):[e-pub ahead of print]

Author(s):

About Research in Context

In this article, the authors of recent scholarship have been asked to discuss the implications of their research on federal health care providers and specifically the veteran and active-duty service member patient populations. Because the article does not include new research and cannot be blinded, it has undergone an abbreviated peer review process. The original article can be found at Tsai J, Shen J. Exploring the link between posttraumatic stress disorder and inflammation-related medical conditions: an epidemiological examination. Psychiatr Q. 2017;88(4):909-916.

References

1. US Department of Veteran Affairs. How common is PTSD? https://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp. Updated October 3, 2016. Accessed September 14, 2018.

2. Pai A, Suris AM, North CS. Posttraumatic stress disorder in the DSM-5: controversy, change, and conceptual considerations. Behav Sci (Basel). 2017;7(1):pii E7.

3. Gupta MA. Review of somatic symptoms in post-traumatic stress disorder. Int Rev Psychiatry. 2013;25(1):86-99.

4. Tsai J, Harpaz-Rotem I, Armour C, Southwick SM, Krystal JH, Pietrzak RH. Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from the National Health and Resilience in Veterans Study. J Clin Psychiatry. 2015;76(5):546-553.

5. Schalinski I, Elbert TR, Schauer M. Cardiac defense in response to imminent threat in women with multiple trauma and severe PTSD. Psychophysiology. 2013;50(7):691-700.

6. National Institute of Mental Health. Post-traumatic stress disorder. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml. Updated February 2016. Accessed September 14, 2018.

7. Sledjeski EM, Speisman B, Dierker LC. Does number of lifetime traumas explain the relationship between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R). J Behav Med. 2008;31(4):341-349.

8. Tsai J, Shen J. Exploring the link between posttraumatic stress disorder and inflammation-related medical conditions: an epidemiological examination. Psychiatr Q. 2017;88(4):909-916.

9. Tulloch H, Greenman PS, Tassé V. Post-traumatic stress disorder among cardiac patients: Prevalence, risk factors, and considerations for assessment and treatment. Behav Sci (Basel). 2014;5(1):27-40.

10. Britvić D, Antičević V, Kaliterna M, et al. Comorbidities with posttraumatic stress disorder (PTSD) among combat veterans: 15 years postwar analysis. Int J Clin Health Psychol. 2015;15(2):81-92.

11. Pacella ML, Hruska B, Delahanty DL. The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review. J Anxiety Disord. 2013;27(1):33-46.

12. Brouwers C, Wolf J, von Känel R. Inflammatory markers in PTSD. In: Martin CR, Preedy VR, Patel VB, eds. Comprehensive Guide to Post-Traumatic Stress Disorder. Zürich, Switzerland: Springer; 2016:979-993.

13. Passos IC, Vasconcelos-Moreno MP, Costa LG, et al. Inflammatory markers in post-traumatic stress disorder: a systematic review, meta-analysis, and meta-regression. Lancet Psychiatry. 2015;2(11):1002-1012.

14. von Känel R, Begré S, Abbas CC, Saner H, Gander ML, Schmid JP. Inflammatory biomarkers in patients with posttraumatic stress disorder caused by myocardial infarction and the role of depressive symptoms. Neuroimmunomodulation. 2010;17(1):39-46.

15. Spitzer C, Barnow S, Völzke H, et al. Association of posttraumatic stress disorder with low-grade elevation of C-reactive protein: evidence from the general population. J Psychiatr Res. 2010;44(1):15-21.

16. Gola H, Engler H, Sommershof A, et al. Posttraumatic stress disorder is associated with an enhanced spontaneous production of pro-inflammatory cytokines by peripheral blood mononuclear cells. BMC Psychiatry. 2013;13:40.

17. Sidney S, Sorel ME, Quesenberry CP, et al. Comparative trends in heart disease, stroke, and all-cause mortality in the United States and a large integrated healthcare delivery system. Am J Med. 2018;131(7):829-836.e1.

18. US Department of Health and Human Service, Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2016: with chartbook on long-term trends in health. https://www.cdc.gov/nchs/data/hus/hus16.pdf. Published May 2017. Accessed September 14, 2018.

19. Weiner J, Richmond TS, Conigliaro J, Wiebe DJ. Military veteran mortality following a survived suicide attempt. BMC Public Health. 2011;11:374.

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Posttraumatic stress disorder (PTSD) develops after exposure to a traumatic event, which can involve witnessing the traumatic event or directly experiencing the trauma. ¹ The prevalence of PTSD in the general population is approximately 7% to 8%. ¹ However, not everyone who experiences trauma develops PTSD since the majority of men and women experience at least 1 traumatic event in their lifetimes but do not develop PTSD. ¹

In order to be diagnosed with PTSD, a patient must meet several criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). ² The patient is required to have exposure to trauma, begin having a certain number of prespecified symptoms, and these symptoms must persist for at least a month. ² Symptoms of PTSD include re-experiencing the traumatic event, avoidance of stimuli associated with the trauma, negative cognitions and mood, and hyperarousal. ^3,4 The hyperarousal that is associated with PTSD has been theorized to be either a result of the trauma experienced or exacerbation of a pre-existing tendency. ⁵ This can manifest in various ways, such as hypervigilance, exaggerated startle response, trouble sleeping, problems concentrating, or irritability. ^3,5 These symptoms can cause individuals with PTSD to have elevated levels of stress and to experience difficulties with completing everyday tasks. ⁶

PTSD and Inflimmation-Related Medical Conditions

Posttraumatic stress disorder has been linked to various physical health problems. Studies have found that PTSD is often comorbid with cardiovascular, autoimmune, musculoskeletal, digestive, chronic pain and respiratory disorders. ^3,7-11 Inflammation may be a contributing factor in the associations between PTSD and these conditions. ^12-16 Studies have found that increases in pro-inflammatory cytokines and interferons are associated with PTSD, as well as changes in immune-related blood cells. ^12-16

Considering that PTSD has been linked to many medical conditions that have inflammatory components, especially cardiovascular disease, inflammatory markers may be early indicators of PTSD. ^12-16 Additionally, inflammatory markers such as cytokines and interferons can be targeted through medications, and potentially influence symptoms. ¹³ However, the relation between PTSD and inflammation remains unclear. Associations between PTSD and inflammation-related medical conditions may be due to confounding variables, such as sociodemographic characteristics and health behaviors. Moreover, the list of inflammation-related medical conditions is long and there is no universal agreement of what conditions are related to inflammation.

We recently conducted an epidemiological study using a representative sample of residents living in New York City and found significant associations between PTSD and some inflammation-related medical conditions. ⁸ We found that participants who had PTSD were more than 4 times more likely to report having had a heart attack or emphysema than were those without PTSD. In addition, participants with PTSD were 2 times more likely to report having hypercholesterolemia, insulin resistance, and angina than were those without PTSD. However, we also found that participants who had PTSD were less likely to develop other inflammation-related conditions like hypertension, type 1 diabetes mellitus, asthma, coronary heart disease, stroke, osteoporosis, and failing kidney.

Together, these associations suggest there is a strong link between PTSD and certain medical conditions, but the link may not be solely based on inflammation. ⁸ Moreover, positive associations between PTSD and hypertension, asthma, and coronary heart disease disappeared when depression was controlled for. This finding points to depression as a major factor, consistent with previous findings that depression is associated with the development of various medical conditions and may be a stronger factor than PTSD. ⁸