The trauma, pain and suffering of our nation's veterans in the recent Iraq and Afghanistan wars has been tremendous. About 20% suffer from Post-Traumatic Stress Disorder (PTSD), a devastating condition characterized by long-term nightmares, feelings of terror, problems in intimate relationships, anger, emotional numbing and suicide risk.The DSMIV-TR, the major diagnostic manual of the American Psychiatric Association conceptualizes PTSD as an Anxiety Disorder and has research-based criteria for its for its diagnosis. Cognitive-Behavioral treatments are effective at decreasing PTSD symptoms and are considered state of the art. Yet I do not consider PTSD to be a mental health problem. Rather, I see it as a chronic, systemic problem of mind-body-spirit in which long-term stress responses deplete both mental and physical health.
I have been trained in Health Psychology and the Biopsychosocial Model (Engel, 1977) which, in contrast to our current fragmented approach to healthcare, does not see mental and physical health problems as separate. Having major depression, for example, substantially elevates the risk of developing chronic pain and heart disease. Research suggests PTSD or its subclinical forms are linked to a chronic or life-threatening medical problems and risky behaviors, many of which may require preventive intervention.
A study conducted by Harvard and Boston University researchers analyzed data from the Veterans Administration Normative Aging Study. Specifically, the researchers compared the health records of male veterans who had completed PTSD symptom questionnaires in 1986 and 1990. The men were followed for 10-15 years and their health status documented. A striking finding was the veterans with more PTSD symptoms were more likely to have heart attacks in subsequent years. The researchers noted that "For each level increase in symptoms on the 1990 assessment, the risk of heart attack or chest pain rose 18 percent - even after controlling for smoking, alcohol use and high blood pressure.". A limitation of the study was that most participants had subclinical levels of PTSD and did not meet full diagnostic criteria. We also don't know if the same results would be found for women. The researchers also didn't measure how frequently the men exercised, so we don't know whether those with more PTSD symptoms were more likely to avoid exercising and this might have accounted for the effect.
Why might PTSD or its symptoms be bad for the veteran's health? Well-designed research studies have found that veterans with PTSD are more likely to smoke cigarettes than those without PTSD. People who are chronically anxious or "on edge" often smoke to calm themselves down or as a nervous habit. Also both experiencing trauma and having PTSD symptoms have been linked to a higher incidence of chronic pain complaints, especially low back pain and headaches. Here the picture gets complicated because many veterans returning from Iraq and Afghanistan also have mild traumatic brain injury (TBI) and have experienced concussions and been injured.This raises a "chicken and egg" problem in that the pain could be due to PTSD, TBI, the combination of the two, or all three conditions could be due to the original injury.
In other research, veterans with PTSD have been shown to have more autoimmune diseases, such as arthritis and psoriasis, than those without. In autoimmune diseases, the immune system becomes overactive, mistaking parts of the person's own body for a foreign object and mounting an immune response resulting in chronic inflammation. In PTSD, the person becomes hypervigiilant to threat, chronically on edge, and more likely to perceive neutral events as dangerous. Being in a constant state of alertness might stress out the heart and make the immune system hyperactive. In other research conducted by the Army, of veterans returning from Iraq, those with PTSD reported worse health status and had more missed workdays in the first year than those without. This raises the spectre of increased financial costs of PTSD due to disability and lower productivity. It is not yet known if these effects continue long-term.
A new research study, summarized this weekend in Science Daily, suggests a possible mechanism for PTSD's link with having shorter life. In this recent study, conducted by researchers at the San Francisco VA Medical Center and the University of California, San Francisco. veterans from Iraq and Afghanistan who were diagnosed with PTSD had shorter telomeres than those without. The study defined telomeres as "DNA-protein complexes that cap the ends of chromosomes and protect them from damage and mutations." They stated that "Short telomere length is associated with an increased risk of cancer, cardiovascular disease, and autoimmune and neurodegenerative diseases, as well as early death." Other analyses indicated that those in the PTSD group with more childhood traumas, including neglect, physical abuse or sexual abuse, had the shortest telomeres. This suggests a possible additive effect of PTSD and childhood traumas in predicting telomere length and risk for early mortality. Unfortunately, the study could not address this question directly because those without PTSD had few childhood traumas.
These results allude to possible hidden financial and personal costs of the wars that the US has participated in. These costs include healthcare, pain and suffering and disability. While mental health aspects of PTSD are widely publicized, less attention has been paid to the longer-term physical health risks. Implications for treatment are that veterans with PTSD should be monitored closely by their doctors, educated about the possible health risks, and given preventive lifestyle and mind-body interventions as well as medications for PTSD. Integrative interventions such as yoga, tai chi, or meditation treat the whole person, may involve breathing stretching, or relaxation, and, if tolerated by the veterans, may be good adjuncts to psychiatric and/or Cognitive-Behavioral treatment for PTSD. Thinking about PTSD as just a mental health issue that can be medicated away does a disservice to our nation's veterans. Instead, seeing PTSD as a complex mind-body problem opens the door for thinking about innovative and integrative healthcare solutions.
Link to the Science Daily article:
link to the Biopsychosocial Model
Melanie Greenberg PhD is a Clinical Health Psychologist with a private practice in Marin County, CA. She specializes in helping individuals deal with life stress due to chronic illness, role demands, traumas and major life transitions. She is also available for workshops and speaking engagements. To find out more about my clinical practice, background, and scientific publications, visit my website at http://melaniegreenbergphd.com/marin-psychologist/. For more articles, check out my blog http://marinpsychologist.blogspot.com.