Psychological Trauma and Physical Health: a Psychoneuroimmunology Approach to Etiology of Negative Health Effects and Possible Interventions
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Psychological Trauma: Theory, Research, Practice, and Policy © 2009 American Psychological Association 2009, Vol. 1, No. 1, 35–48 1942-9681/09/$12.00 DOI: 10.1037/a0015128 Psychological Trauma and Physical Health: A Psychoneuroimmunology Approach to Etiology of Negative Health Effects and Possible Interventions Kathleen Kendall-Tackett Texas Tech University School of Medicine People who have experienced traumatic events have higher rates than the general population of a wide range of serious and life-threatening illnesses including cardio- vascular disease, diabetes, gastrointestinal disorders, and cancer. An important ques- tion, for both researchers and clinicians, is why this occurs. Researchers have discov- ered that traumatic events dysregulate the hypothalamic-pituitary-adrenal axis and sympathetic nervous system. More recently, research from the field of psychoneuro- immunology (PNI) suggests that traumatic life events can lead to health problems through dysregulation of another key system: the inflammatory response. Prior trauma “primes” the inflammatory response system so that it reacts more rapidly to subsequent life stressors. Elevated inflammation has an etiologic role in many chronic illnesses. Recent PNI studies also suggest some interventions that can serve as adjuncts to traditional trauma treatment. These treatments include long-chain omega-3 fatty acids, exercise, and sleep interventions. Each of these interventions downregulates inflam- mation, which will likely halt the progression to chronic disease for some trauma survivors. Keywords: trauma, inflammation, depression, PTSD, omega-3s For more than a decade, researchers have Trauma Increases the Risk of Health explored the impact of traumatic events on Problems physical health. Trauma survivors often have significant physical health problems that can The Adverse Childhood Experiences (ACE) linger for many years after the traumatic event study, with more than 17,000 participants from has ended and are often above and beyond the a large California health maintenance organiza- effects of direct physical injury (Kendall- tion (HMO), was the first large-scale study to Tackett, 2007; Kibler, Joshi, & Hughes, in demonstrate the link between childhood trauma press). The question of trauma’s impact and and organic health conditions. Felitti and col- health is at the junction of mind-body medicine. leagues (1998) found that patients who experi- It has important implications for not only health enced four or more types of adverse childhood care costs, but also for trauma practice, and how events had higher rates of ischemic heart dis- we can best meet the needs of people who have ease, cancer, stroke, chronic bronchitis, emphy- experienced trauma. In this article, I review sema, diabetes, skeletal fractures, and hepatitis research on psychological trauma and physical than their nontraumatized counterparts. The health using a psychoneuroimmunology (PNI) childhood events they studied included all types approach. PNI research can describe some of of maltreatment including psychological, phys- the possible mechanisms by which trauma af- ical, or contact sexual abuse and exposure to fects health. It also suggests some viable addi- parental substance abuse, mental illness, inti- tions to traditional trauma treatments that will mate partner violence, or criminal behavior. address the physical health sequelae. Since publication of that study, others have followed with similar findings. In the National Comorbidity Study, women who were mal- Correspondence concerning this article should be ad- treated as children had a ninefold increase in dressed to Kathleen Kendall-Tackett, Department of Pedi- atrics, Texas Tech University School of Medicine, 1400 N. cardiovascular disease compared with nonmal- Coulter Street, Rm 4301, Amarillo, TX 79106. E-mail: treated women (Batten, Aslan, Maciejewski, & [email protected] Mazure, 2004). In a sample of primary care 35 36 KENDALL-TACKETT patients, those who experienced childhood Leserman, and colleagues (Drossman, Li, abuse or partner violence in adolescence or Leserman, Toomey, & Hu, 1996; Leserman et adulthood reported twice as many symptoms on al., 1996) found that 60% of women in treat- a review of systems than their age-matched, ment for functional gastrointestinal (GI) illness nonabused counterparts. They were also more (such as irritable bowel syndrome) had a history likely to abuse substances and report a wide of abuse, as children or adults. In another study variety of chronic pain syndromes (Kendall- (Drossman, Leserman, Li, Keefe, Hu, & Tackett, Marshall, & Ness, 2000, 2003). Toomey, 2000), half of the women referred to a Patients with diagnoses of posttraumatic GI treatment center had been physically or sex- stress disorder (PTSD) report similar symp- ually abused. Fourteen percent reported severe toms. Data from the Canadian Community abuse. Patients who had been more severely ϭ Health Survey (N 36,984) indicated that par- abused had poorer health status relative to the ticipants with PTSD had significantly higher other patients. rates of cardiovascular disease, respiratory dis- Sachs-Ericsson, Kendall-Tackett, and Her- eases, chronic pain syndromes, gastrointestinal nandez (2007), using data from the National illnesses, and cancer (Sareen, Cox, Stein, Afifi, Comorbidity Study, noted that patients with a Fleet, & Asmundson, 2007). PTSD was also history of childhood or partner abuse reported strongly associated with chronic fatigue syn- more pain when describing their current health drome and multiple-chemical sensitivity, but symptoms. Van Houdenhove, Luyten, and Egle not diabetes. PTSD following a human-made disaster (2009) found that 64% of patients who had showed similar health effects (N ϭ 896; either fibromyalgia or chronic fatigue syndrome Dirkzwager, van der Velden, Grievink, & had experienced at least one type of either child Yzermans, 2007). In this study, PTSD was as- or adult trauma. More concerning was that 39% sociated with new vascular events as well as had experienced both, indicating a lifelong pat- physician-reported vascular, musculoskeletal, tern of revictimization and abuse. and dermatological problems. These problems appeared even after controlling for previous Possible Mechanisms: The health problem, smoking, and demographic characteristics. Psychoneuroimmunology of Trauma Not surprisingly, people with PTSD use more The negative health effects of trauma and health care services than those without PTSD. PTSD, at this point, are fairly well established. In a study of women seeking health care at A wide range of traumatic exposures and expe- Veterans’ Administration facilities (Dobie et riences can lead to poor health. Some of this is al., 2006), women with PTSD had more outpa- attributable directly to injury suffered during tient visits to the emergency department, pri- mary care, medical or surgery subspecialities, the trauma. Others result from the effects of the ancillary services, and diagnostic tests. They trauma. The question then becomes why does had higher rates of hospitalizations and surgical this occur? It’s an important question to ask procedures. Women with PTSD were signifi- because it has implications for not only treating cantly more likely to have a service-related dis- trauma survivors currently seeking care, but ability, have chronic pain, and to be obese. They also for prevention of these health problems in were also more likely to smoke and abuse alco- the future. hol. Seventy-five percent of the women with Research in the field of PNI is a useful PTSD also screened positive for depression. framework for understanding these effects. According to PNI research, many of these Trauma and Chronic Pain illnesses are because severe or overwhelming stress, and any resultant PTSD, alters and Researchers studying chronic pain syn- dysregulates the key systems that are part of dromes were among the first to note an associ- the stress response. To understand these find- ation between trauma and health (Gross, Doerr, ings, it’s helpful to review the three compo- Caldirola, Guzinski, & Ripley, 1980; Harrop- nents of the stress system. These are de- Griffiths et al., 1988). For example, Drossman, scribed in the following section. PSYCHOLOGICAL TRAUMA AND PHYSICAL HEALTH 37 How Humans Respond to a Perceived interleukin 1- (IL-1), interleukin-6 (IL-6), Threat tumor necrosis factor-␣ (TNF-␣), and inter- feron-␥ (IFN-␥). These findings are an impor- Human bodies have a number of interdepen- tant part of the picture when studying the health dent mechanisms in place designed to preserve effects of traumatic events and are the focus of life in the face of danger: catecholamine, hypo- this article. thalamic-pituitary-adrenal (HPA) axis, and im- The human stress response has a number of mune response. In response to threat, the sym- checks and balances built in to ensure that var- pathetic nervous system responds by releasing ious components do not become overactive. Un- the catecholamines norepinephrine, epineph- fortunately, in the case of severe or overwhelm- rine, and dopamine. This is the fight-or-flight ing stress, the normal checks and balances fail, response. The HPA axis responds with a chem- causing inflammation levels to be abnormally ical cascade: the hypothalamus releases cortico- high. For example, cortisol (which is normally trophin-releasing hormone (CRH), which antiinflammatory and keeps proinflammatory causes the pituitary to release adrenocortico- cytokines in check) can actually change func-