1. Physical Health Effects of Traumatic Exposure Paula P. Schnurr, Ph.D. National Center for PTSD Executive Division, & Dartmouth Medical School

2. 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

3. 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…”

4. 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

5. What Are Health Outcomes? Influence Due to Mental HealthExample Self-reports Symptoms+++PILL, SCL-90 Global status++SF-36 Functioning++SF-36 Conditions+“Has a doctor ever told you that you have...?” Utilization +Self-report, database Morbidity Physician exam(+)Review of systems Laboratory tests0EKG Mortality 0Standardized mortality ratio

6. 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

7. Findings on Trauma and Poor Health Self- ReportUtilizationMorbidityMortality Military ++++/-+ Sexual +++++/-NA Disaster ++++++/- Other ++NA++ ++ = clear association, + = probable association, +/- = inconsistent information, NA = insufficient information

8. Health Outcomes as a Function of Childhood Trauma

9. Health Risk Behaviors as a Function of Childhood Trauma

10. Wartime Stress and Coronary Artery Disease in Civilians (Sibai et al., 1989) Cases more likely than controls to have high exposure to war stressors

11. 10-Year Mortality in War-Exposed Civilians (Sibai et al., 2001)

12. Questions??? How does traumatic exposure lead to poor health?

13. How Does Trauma Lead to Poor Health? The Role of Distress as a Mediator Distress Stressful Event Physical Health Outcome Trauma PTSD Health

14. 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**

15. 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 # Medical Conditions # Medical Conditions.42**.08 WZ Exposure WZ Exposure

16. Findings on PTSD and Poor Health Self- ReportUtilizationMorbidityMortality Military+++++ Sexual++++NA Disaster+++NA Other+++NA ++ = clear association, + = probable association, NA = insufficient information

17. Odds of Self-Reported Medical Disorder Due to PTSD in Female Vietnam Veterans (Wolfe et al., 1994) OR indicates change associated w/1.0 SD in PTSD symptoms Adjusted for age, education, and WZE *p <.05 * * * * *

18. Adjusted Odds of Self-Reported Medical Disorder Due to PTSD in Vietnam Veterans (Boscarino, 1997) *p <.05 * * * * * *

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

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

21. Adjusted Annual Cost Ratios in Female HMO Enrollees (Walker et al., 2003) PCL med = 30-44, high = 45+ *p <.05 adjusted for demographics, chronic disease, and mental health * * * *

22. PTSD and Hazard of Physician- Diagnosed Disease in Older Veterans (Schnurr, Spiro, & Paris, 2000) Hazard is expressed per 10-pt increase in PTSD sxs and is adjusted for age, BMI, smoking, and alcohol consumption *p <.05 * * * *

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

24. Odds of Physician-Diagnosed Disorder as a Function of PTSD Diagnosis (Ouimette et al., 2004) * * Gender did not moderate the effects of PTSD *p <.05, adjusted for age, smoking, alcohol, BMI

25. Mortality Due to PTSD in Vietnam Veterans (Bullman & Kang, 1994) * * *p <.05

26. Questions??? How does traumatic exposure lead to poor health? Are the effects of PTSD unique from the effects of other psychiatric disorders?

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

28. Odds of Cardiovascular Problems in Vietnam Veterans with PTSD (Boscarino & Chang, 1999) N = 4,462 Adjusted for demographic, military, and health risk covariates. *p <.05

29. Medical Service Utilization in Male Vietnam Veterans (Schnurr et al., 2000) *p <.05

30. 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???

31. Case-Control Study of High v. Low VA Healthcare Users (Deykin et al., 2001) Effects of PTSD on number of medical conditions both direct and mediated through depression OR of PTSD in High v. Low Users = 2.17

32. Effects of PTSD and Depression on Health Status in Peacekeepers (Asmundson et al., 2002) *p <.01 PTSD Depression Poor Health AlcoholUse.24*.81*.40*.17*

33. Possible Ways PTSD Could Affect Health

34. 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)

35. 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

36. Allostasis and Allostatic Load

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

38. PTSD and Allostatic Load (Schnurr & Jankowski, 1999) other risk factors sympathetic activation self-medication (smoking & drinking) stress due to drinking consequences    Allostatic Load Threshold for illness

39. Multifactorial Model of Trauma, PTSD, & Health (Schnurr & Green, 2004) PTSD Exposure Biological Alterations Psychological Alterations Attentional Processes Health Risk Behaviors Illness Behavior Disease

40. (1) Exposure affects health primarily through PTSD and other distress reactions PTSD Exposure Biological Alterations Psychological Alterations Attentional Processes Health Risk Behaviors Illness Behavior Disease

41. (2) PTSD and distress reactions affect illness behavior by altering symptom perception PTSD Exposure Biological Alterations Psychological Alterations Attentional Processes Health Risk Behaviors Illness Behavior Disease

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

43. 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

44. 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