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Physical Health Problems After Single Trauma Exposure: When Stress JAP17610.1177/1078390311425187D’Andr 425187ea et al.Journal of the American Psychiatric Nurses Association Original Articles Journal of the American Psychiatric Nurses Association Physical Health Problems After Single 17(6) 378 –392 © The Author(s) 2011 Reprints and permission: http://www. Trauma Exposure: When Stress Takes sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390311425187 Root in the Body http://jap.sagepub.com Wendy D’Andrea1, Ritu Sharma2, Amanda D. Zelechoski3, and Joseph Spinazzola4 Abstract Research has established that chronic stress, including traumatic events, leads to adverse health outcomes. The literature has primarily used two approaches: examining the effect of acute stress in a laboratory setting and examining the link between chronic stress and negative health outcomes. However, the potential health impact of a single or acute traumatic event is less clear. The goal of this literature review is to extend the literature linking both chronic trauma exposure and posttraumatic stress disorder to adverse health outcomes by examining current literature suggesting that a single trauma may also have negative consequences for physical health. The authors review studies on health, including cardiovascular, immune, gastrointestinal, neurohormonal, and musculoskeletal outcomes; describe potential pathways through which single, acute trauma exposure could adversely affect health; and consider research and clinical implications. Keywords posttraumatic stress trauma, health, health behavior, comorbidity The question of how trauma affects health is highly salient, The association between health outcome and chronic given the prevalence of trauma in our society. Estimates traumatization have been researched extensively (Irish, vary, but the most comprehensive and nationally representa- Kobayashi, & Delahanty, 2010; Neumann, Houskamp, tive prevalence study to date indicates that at least 60% of Pollock, & Briere, 1996), and concepts such as allostatic men and 51% of women in the general population report load have been elaborated to help study the connection experiencing at least one traumatic event in their lives between chronic stress exposure and health burden (for (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). In review, see Friedman & McEwen, 2004). What remain Kessler et al.’s study, the three most commonly experienced less clear are whether and how exposure to more circum- types of trauma were witnessing someone being badly scribed trauma could bear similar weight and the pro- injured or killed; being involved in a fire, flood, or natural cesses leading to illness. disaster; and being involved in a life-threatening accident. Our premise is this: Trauma sets the stage for ongoing In addition to single-incident or acute trauma exposure, psychological and physical distress, which can mutually affect chronic or complex trauma exposure is prevalent in our cul- one another, possibly for the duration of the survivor’s ture. Exposure to early life adversity, such as physical abuse, sexual abuse, and neglect are common: Approximately one third of children are estimated to experience physical abuse 1Wendy D’Andrea, PhD, The New School, New York, NY, USA 2 (Anda et al., 1999); approximately one in four girls and one Ritu Sharma, PhD, The Trauma Center at Justice Resource Institute, in five boys experience sexual victimization during child- Brookline, MA, USA 3Amanda D. Zelechoski, JD, PhD, Valparaiso University, Valparaiso, hood (Finkelhor, Hotaling, Lewis, & Smith, 1990). Other IN, USA forms of nonabuse trauma, such as exposure to community 4Joseph Spinazzola, PhD, The Trauma Center at Justice Resource violence, are also common (Bell & Jenkins, 1993). Such Institute, Brookline, MA, USA forms of trauma are notable because they occur repeatedly Corresponding Author: over key developmental periods, thereby increasing the Wendy D’Andrea, Department of Psychology, The New School, 80 likelihood of negative outcomes via chronic activation of Fifth Avenue, 6th Floor, New York, NY 10011, USA stress response systems. Email: [email protected] D’Andrea et al. 379 life span. The purpose of this review is to examine the may be acute (lasting moments or hours) or chronic empirically derived basis for whether and how acute (lasting months or years). Physiological arousal is mea- trauma exposure could adversely affect physical health. sured as both tonic (e.g., baseline or trait) and phasic First, we will examine how this could occur using the fol- (e.g., change from baseline in response to an experi- lowing chain of reasoning: (a) that in early development mental stimulus). As we will argue here, an acute event the impact of trauma exposure is seen in dose–response may nonetheless have a chronic impact. Finally, the relationships to the leading causes of death, (2) that it term somatization, arising from the psychoanalytic lit- causes posttraumatic psychopathology that can be chronic erature, refers to the process of expressing psychologi- and accrue comorbidities, (3) that trauma exposure can cal distress in physical terms, as a defense for keeping have a unique, independent association with health outcomes, psychological distress and conflicts out of awareness but (4) that trauma’s psychological impact, mediated via (Lipowski, 1988). Generally, somatization refers to impacts on the neuropsychiatric system, may relate to physiological distress in the absence of any physical long-term health outcomes through two pathways: (a) the indicators of disease. “cues” or triggered reminders that sustain the association Of course these terms and their suggested precision of the trauma exposure to distress and, in turn, to adverse are somewhat misleading. A traumatic event may not reg- health outcomes and (b) the demands that may be attrib- ister as such for an individual whose level of daily stress uted to emotional management techniques such as sup- is extremely elevated. Conversely, for someone already pression and dissociation. We hypothesize that these burdened and depleted by extreme stress, an event that processes turn an acute event into a chronic one. might be otherwise manageable might be processed as a traumatic event. Similarly, a traumatic event may not be “over” when it is over; in the eyes of the PTSD sufferer, Definitions and Caveats the event may be reexperienced as intensely as when the One area of confusion and ambiguity within this litera- event first occurred. The result is that the lines between ture is related to thresholds distinguishing several con- acute and chronic and between event and outcome cepts: “acute” and “chronic,” “exposure” and “impact,” become unclear, creating ambiguity in how we interpret and “trauma” and “stress.” Some of the confusion arises research findings. This ambiguity is reflected in the because the reality is that creating thresholds between research: Many studies attempting to capture the impact continuous constructs creates a false dichotomy. None- of acute traumatic events have not thoroughly included theless, for our purposes, a clarification of how terms will measures of premorbid trauma exposure or level of life be used in this article may leave the reader with a more stress. The findings presented herein may be character- precise understanding of what research has definitively ized by some of these flaws. We will provide as much stated, and what remains ambiguous. “Trauma” will refer precision as possible. to events, rather than their potential consequences, and will be used consistent with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision Chronicity of Exposure Is (DSM-IV-TR; American Psychiatric Association, 2000) Related to Health Outcomes definition: a discrete event or events with threat to life or Multiple exposures to traumatic event can greatly affect bodily integrity that result in fear, helplessness, or horror. the intensity of not only the psychological symptoms but In contrast, stressors are mild to extreme demands. Stress also the physical symptoms. The Adverse Childhood is a state of burdened response to stressors, resulting in Experiences Study (Anda et al., 2006; Felitti et al., 1998) deterioration and dysfunction (Selye, 1956). Traumatic is one of the most powerful studies to document such find- events or trauma exposure refers to the actual events ings. Felitti et al. surveyed more than 16,000 adults with themselves: car accidents, assaults, abuse, natural disas- health insurance. Of the risk factors investigated (e.g., ters. Posttraumatic stress, posttraumatic symptoms, and trauma exposure in childhood and adulthood, health posttraumatic stress disorder (PTSD; as defined by the behaviors, and potential genetic factors), childhood DSM-IV-TR) refer to the client-reported distress attrib- trauma exposure accounted for negative health outcomes uted to traumatic events (e.g., feeling upset in response to across multiple diagnoses, from psychiatric (depression, reminders, wanting to avoid places related to the trauma). anxiety, substance abuse) to physical (diabetes, heart dis- So, too, does psychiatric distress refer to the client’s self- ease, and cancer). Risk for disease increased linearly with reported emotional distress, rather than possible underly- exposure to multiple forms of traumatization. Similarly, ing or unconscious pathology or other psychological using data from the National Comorbidity Survey processes. Traumatization refers to the process by Replication, Sledjeski, Speisman, and Dierker’s (2008) which
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