Posttraumatic stress disorder, cardiovascular disease outcomes and the modifying role of socioeconomic status

INTRODUCTION

Substantial evidence indicates that post-traumatic stress disorder (PTSD) is associated with an increased incidence of cardiovascular disease (CVD), and differential PTSD-CVD association by socioeconomic status had been suggested. However, there are inadequate evidence on differential association. This study investigated sociodemographic heterogeneity in the association between PTSD and CVD.

METHODS

A total of 53,749 patients diagnosed with PTSD in 2004-2018 were recruited from Korean National Health Insurance Database. Date of first diagnosis of PTSD was set as an index date. We recruited 3 controls per each patient, matched by age and sex (N = 161,247). Monthly insurance premiums were used as a surrogate variable for socioeconomic status. Cox proportional hazard model was used to estimate the hazard of incident coronary artery disease, incident stroke, and cardiovascular mortality. We stratified participants by age, sex, and insurance premium to test heterogeneities in the association.

RESULTS

PTSD was associated with increased risk for coronary artery disease, hemorrhagic stroke, and cardiovascular mortality. Elevation in risk of cardiovascular disease was more prominent in younger individuals. PTSD increased the risk of coronary artery disease and ischemic stroke more in individuals with lower SES, especially in men.

LIMITATIONS

Insurance premium might not fully represent socioeconomic status of individual. Misclassification or misdiagnosis of PTSD by might have introduced biases.

CONCLUSIONS

PTSD was associated with increased incidence of CVD, particularly in male patients with low SES. For PTSD patients with lower SES, preventive measures against cardiovascular disease would be able to decrease the disease burden of cardiovascular comorbidity in PTSD.

Posttraumatic Stress Disorder (PTSD) as a Risk Factor for Cardiovascular Disease: Implications for Future Research and Clinical Care

PURPOSE OF REVIEW

Posttraumatic stress disorder (PTSD) may be an important risk factor for cardiovascular disease (CVD). We explore the literature linking PTSD to CVD, potential mechanisms, interventions, and clinical implications. We outline gaps in current literature and highlight necessary future research.

RECENT FINDINGS

PTSD has been independently associated with deleterious effects on cardiovascular health through biological, behavioral, and societal pathways. There are evidence-based psychotherapeutic interventions and pharmacotherapies for PTSD that may mitigate its impact on CVD. However, there are limited studies that rigorously analyze the impact of treating PTSD on cardiovascular outcomes. Trauma-informed CVD risk stratification, education, and treatment offer opportunities to improve patient care. These approaches can include a brief validated screening tool for PTSD identification and treatment. Pragmatic trials are needed to test PTSD interventions among people with CVD and evaluate for improved outcomes.

Trauma, psychological distress and markers of systemic inflammation among US women: A longitudinal study

BACKGROUND

Prior evidence links posttraumatic stress disorder (PTSD) and depression, separately, with chronic inflammation. However, whether effects are similar across each independently or potentiated when both are present is understudied. We evaluated combined measures of PTSD and depression in relation to inflammatory biomarker concentrations.

METHODS

Data are from women (n's ranging 628-2797) in the Nurses' Health Study II. Trauma exposure, PTSD, and depression symptoms were ascertained using validated questionnaires. We examined (a) a continuous combined psychological distress score summing symptoms for PTSD and depression, and (b) a categorical cross-classified measure of trauma/PTSD symptoms/depressed mood status (reference group: no trauma or depressed mood). Three inflammatory biomarkers (C-reactive protein [CRP], interleukin-6 [IL-6], tumor necrosis factor alpha receptor 2 [TNFR2]) were assayed from at least one of two blood samples collected 10-16 years apart. We examined associations of our exposures with levels of each biomarker concentration (log-transformed and batch-corrected) as available across the two time points (cross-sectional analyses; CRP, IL-6 and TNFR2) and with rate of change in biomarkers across time (longitudinal analyses; CRP and IL-6) using separate linear mixed effects models.

RESULTS

In sociodemographic-adjusted models accounting for trauma exposure, a one standard deviation increase in the continuous combined psychological distress score was associated with 10.2% (95% confidence interval (CI): 5.2-15.4%) higher CRP and 1.5% (95% CI: 0.5-2.5%) higher TNFR2 concentrations cross-sectionally. For the categorical exposure, women with trauma/PTSD symptoms/ depressed mood versus those with no trauma or depressed mood had 29.5% (95% CI: 13.3-47.9%) higher CRP and 13.1% (95% CI: 5.1-21.7%) higher IL-6 cross-sectionally. In longitudinal analysis, trauma/PTSD symptoms/depressed mood was associated with increasing CRP levels over time.

CONCLUSIONS

High psychological distress levels with trauma exposure is associated with elevated inflammation and is a potential biologic pathway by which distress can impact development of inflammatory-related chronic diseases, such as cardiovascular disease. Considering multiple forms of distress in relation to these pathways may provide greater insight into who is at risk for biologic dysregulation and later susceptibility to chronic diseases.

Early Life Adversity and Clinical Intimate Partner Violence in Adulthood: The Mediating Role of Interpersonal Conflict in Adolescence

Intimate partner violence (IPV) is associated with adverse outcomes for both victims and perpetrators, though there is significant heterogeneity in manifestations of relationship violence. A growing amount of research has focused on elucidating predictors of clinical IPV-defined as severe violence involving institutional or medical intervention due to actual or potential injury-so as to better understand potential prevention and intervention targets. Early life adversity (ELA) is associated with IPV in adulthood, yet this literature focuses on discrete, retrospectively reported adversities (e.g., physical abuse and neglect) and has yet to consider clinical IPV as an outcome. Little is known about if and how broadly adverse early environments may confer risk for this specific form of relationship violence. We investigated associations between exposure to ELA prior to age five and clinical IPV victimization and perpetration by age 20 in a longitudinal, community-based sample of men and women in Australia (N = 588). Early life adversity was prospectively indexed by maternal reports of financial hardship, child chronic illness, maternal stressful life events, maternal depressive symptoms, parental discord, and parental separation. Youth interpersonal conflict life events at age 15-an interviewer-rated assessment of episodic stressors involving conflict across relationships in mid-adolescence-was tested as a potential mediator for both victims and perpetrators. Among women, ELA predicted IPV victimization and perpetration, and interpersonal conflict life events partially mediated the link between ELA and victimization, but not perpetration. Neither ELA nor interpersonal conflict life events predicted victimization or perpetration among men. Women exposed to ELA are at-risk for conflictual interpersonal relationships later in life, including violent intimate relationships, and deficits in conflict resolution skills may be one mechanism through which ELA leads to IPV victimization among this subgroup. Violence prevention and intervention efforts should target interpersonal skills, including conflict resolution, among women and girls exposed to adverse early environments.

Posttraumatic stress disorder and coping strategies in the postpartum period: A symptomics approach

Posttraumatic stress disorder (PTSD) has been increasingly recognized as a potential mental health concern for new mothers. Elevated PTSD symptoms have been associated with maladaptive coping strategies in the postpartum period, a time when women face many challenges, demands, and stressors. However, PTSD symptoms manifest in heterogeneous ways, and focusing only on total symptom scores may obscure more nuanced associations with particular coping styles. In a large, ethnically diverse sample of postpartum women from across the United States (N = 1,315), first we examined associations between total PTSD symptom severity with three distinct coping styles: active-emotional, avoidant-emotional, and problem-focused. In models adjusting for race and educational attainment, total PTSD symptom severity was significantly positively associated with tendencies to use active- and avoidant-emotional, but not problem-focused, coping. We then adopted a novel "symptomics" approach, employing relative importance analyses to examine associations between individual PTSD symptoms with the coping styles. These analyses identified PTSD symptoms that were most strongly associated with each coping style. Notably, whereas several symptoms explained variance in avoidant-emotional coping, only a few symptoms contributed most to active-emotional and problem-focused coping. Moreover, non-specific symptoms of PTSD that are shared with other psychopathology (e.g., difficulty concentrating, loss of interest) explained significant proportions of variance across all coping styles. Collectively, results suggest that a symptomics approach may provide more nuanced insight into how PTSD symptoms are linked to various coping styles in postpartum women, which can help inform potential screening and intervention targets for at-risk women during this period.

Posttraumatic stress disorder (PTSD), sleep, and cardiovascular disease risk: A mechanism-focused narrative review

OBJECTIVE

Growing longitudinal research has demonstrated that posttraumatic stress disorder (PTSD) precedes and predicts the onset of cardiovascular disease (CVD), and a number of physiological (e.g., dysregulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, chronic systemic inflammation) and behavioral (e.g., physical inactivity, smoking, poor diet) factors might underlie this association. In this narrative review, we focus on sleep as a modifiable risk factor linking PTSD with CVD.

METHOD

We summarize the evidence for sleep disturbance after trauma exposure and the potential cardiotoxic effects of poor sleep, with an emphasis on mechanisms. In addition, we review the literature that has examined sleep in the context of the PTSD-CVD risk relation.

RESULTS

Although sleep disturbance is a hallmark symptom of PTSD and a well-established risk factor for the development of CVD, the role of sleep in the association between PTSD and CVD has been largely unexamined in the extant literature. However, such work has the potential to improve our understanding of mechanisms of risk and inform intervention efforts to offset elevated CVD risk after trauma.

CONCLUSIONS

We outline several recommendations for future research and behavioral medicine models in order to help define and address the role of sleep behavior in the development of CVD among trauma-exposed individuals with PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Posttraumatic stress disorder symptoms and timing of menopause and gynecological surgery in the Nurses' Health Study II

BACKGROUND

Earlier menopause, either natural or through gynecologic surgeries, has been associated with various negative health sequelae. While posttraumatic stress disorder (PTSD) has been linked to dysregulated biological processes, including reproductive system changes that could alter menopausal timing, little work has examined whether trauma and PTSD are associated with greater risk of early cessation of menses.

METHODS

Data are from 46,639 women in the Nurses' Health Study II, a prospective cohort study of women followed for up to 26 years. Lifetime trauma and PTSD symptoms were assessed with the Brief Trauma Questionnaire and a PTSD symptom screener in 2008. Age at cessation of menses and reason for cessation of menses (i.e., natural menopause, gynecologic surgery including hysterectomy and/or bilateral salpingo-oophorectomy [BSO]) were assessed. Cox proportional hazards models estimated hazards ratios (HR) of cessation of menses (separately for naturally or surgically) associated with trauma alone or PTSD symptoms, relative to no trauma, adjusting for covariates.

RESULTS

Trauma/PTSD status was associated with earlier cessation of menses due to surgery, but not natural menopause. Women with trauma exposure, low, and high PTSD symptoms had higher hazard of cessation of menses due to surgery relative to those with no trauma exposure (HR_trauma = 1.16, 95%CI 1.07-1.26; HR_{low PTSD} = 1.25, 95%CI 1.15-1.36; HR_{high PTSD} = 1.29, 95%CI 1.17-1.42). Trauma exposure and PTSD symptoms were associated with similarly increased risk of hysterectomy and BSO surgeries.

CONCLUSIONS

Women who experienced trauma and PTSD may be at elevated risk for common gynecological surgeries premenopausally, potentially due to increased clinical indications or gynecological conditions.

Association of Posttraumatic Stress Disorder With Accelerated Cognitive Decline in Middle-aged Women

IMPORTANCE

Posttraumatic stress disorder (PTSD) has been hypothesized to lead to impaired cognitive function. However, no large-scale studies have assessed whether PTSD is prospectively associated with cognitive decline in middle-aged adults.

OBJECTIVE

To assess the association between PTSD and decline in cognitive function over time.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included participants from the Nurses' Health Study II, an ongoing longitudinal cohort study involving community-dwelling middle-aged female nurses residing in the US who had at least a 2-year nursing degree at the time of enrollment in 1989. The present study included 12 270 trauma-exposed women who were enrolled in the PTSD substudy of the Nurses' Health Study II and completed 1 to 5 cognitive assessments. Data were collected from March 1, 2008, to July 30, 2019.

EXPOSURES

Lifetime PTSD symptoms, assessed using a validated questionnaire between March 1, 2008, and February 28, 2010.

MAIN OUTCOMES AND MEASURES

The main outcome was evaluated using the Cogstate Brief Battery, a self-administered online cognitive battery. Cognitive function was measured by a psychomotor speed and attention composite score and a learning and working memory composite score. Women completed the Cogstate Brief Battery every 6 or 12 months (up to 24 months) from October 3, 2014, to July 30, 2019. Linear mixed-effects models were used to evaluate the association of PTSD symptoms with the rate of change in cognition over follow-up, considering a broad range of relevant covariates, including the presence of depression symptoms and history of clinician-diagnosed depression. The rate of cognitive change was adjusted for potential practice effects (ie, potential changes in test results that occur when a test is taken more than once) by including indicators for the number of previous tests taken.

RESULTS

Among 12 270 women, the mean (SD) age at the baseline cognitive assessment was 61.1 (4.6) years; 125 women (1.0%) were Asian, 75 (0.6%) were Black, 156 (1.3%) were Hispanic, 11 767 (95.9%) were non-Hispanic White, and 147 (1.2%) were of other race and/or ethnicity. A higher number of PTSD symptoms was associated with worse cognitive trajectories. Compared with women with no PTSD symptoms, women with the highest symptom level (6-7 symptoms) had a significantly worse rate of change in both learning and working memory (β = -0.08 SD/y; 95% CI, -0.11 to -0.04 SD/y; P < .001) and psychomotor speed and attention (β = -0.05 SD/y; 95% CI, -0.09 to -0.01 SD/y; P = .02), adjusted for demographic characteristics. Associations were unchanged when additionally adjusted for behavioral factors (eg, 6-7 symptoms in the analysis of learning and working memory: β = -0.08 SD/y; 95% CI, -0.11 to -0.04 SD/y; P < .001) and health conditions (eg, 6-7 symptoms in the analysis of learning and working memory: β = -0.08 SD/y; 95% CI, -0.11 to -0.04 SD/y; P < .001) and were partially attenuated but still evident when further adjusted for practice effects (eg, 6-7 symptoms in the analysis of learning and working memory: β = -0.07 SD/y; 95% CI, -0.10 to -0.03 SD/y; P < .001) and comorbid depression (eg, 6-7 symptoms in the analysis of learning and working memory: β = -0.07 SD/y; 95% CI, -0.11 to -0.03 SD/y; P < .001).

CONCLUSIONS AND RELEVANCE

In this large-scale prospective cohort study, PTSD was associated with accelerated cognitive decline in middle-aged women, suggesting that earlier cognitive screening among women with PTSD may be warranted. Given that cognitive decline is strongly associated with subsequent Alzheimer disease and related dementias, better understanding of this association may be important to promote healthy aging.

Trauma, Post-Traumatic Stress Disorder, and Treatment Among Middle-Aged and Older Women in the Nurses' Health Study II

OBJECTIVE

Trauma and post-traumatic stress disorder (PTSD) are common among women and associated with negative health outcomes across the life course. Relatively few studies, however, have examined the epidemiology of trauma, PTSD, and treatment among middle-aged and older civilian women, who are at elevated risk for adverse health outcomes. We aimed to characterize trauma, PTSD, and trauma-related treatment prevalence and correlates in a large cohort of middle-aged and older women.

DESIGN

Cross-sectional, nested substudy within the Nurses' Health Study II cohort.

SETTING

United States, 2018-2020.

PARTICIPANTS

33,327 current or former nurses, aged 53-74 years.

MEASUREMENTS

16-item modified version of the Brief Trauma Questionnaire; modified PTSD Checklist for the Diagnostic and Statistical Manual, Version 5.

RESULTS

The majority (82.2%) of women reported one or more lifetime traumas. The most common trauma types were unexpected death of a loved one (44.9%) and interpersonal violence (43.5%). Almost 30% reported occupational (nursing-related) trauma. Among the trauma-exposed, 10.5% met criteria for lifetime PTSD and 1.5% had past-month PTSD. One-third of lifetime PTSD cases were due to interpersonal violence event types. One-third of women with lifetime PTSD-and nearly half of those with PTSD from a nursing-related trauma-reported never receiving trauma-related treatment. Women aged 65 years and older with PTSD were less likely to be in treatment than those aged less than 65 years.

CONCLUSION

History of trauma and PTSD is prevalent in this population, and a treatment gap persists. Addressing this treatment gap is warranted, particularly among older women and those with nursing-related trauma.

Epigenetics of early-life adversity in youth: cross-sectional and longitudinal associations

BACKGROUND

Altered DNA methylation (DNAm) may be one pathway through which early-life adversity (ELA) contributes to adverse mental and physical health outcomes. This study investigated whether the presence versus absence of ELA experiences reflecting the dimensions of threat and deprivation were associated with epigenome-wide DNAm cross-sectionally and longitudinally in a community-based sample of children and adolescents.

METHODS

In 113 youths aged 8-16 years with wide variability in ELA, we examined associations of abuse (physical, sexual, emotional; indicating threat-related experiences) and neglect (emotional, physical; indicating deprivation-related experiences) with DNAm assessed with the Illumina EPIC BeadChip array, with DNA derived from saliva. In cross-sectional epigenome-wide analyses, we investigated associations of lifetime abuse and neglect with DNAm at baseline. In longitudinal epigenome-wide analyses, we examined whether experiencing abuse and neglect over an approximately 2-year follow-up were each associated with change in DNAm from baseline to follow-up.

RESULTS

In cross-sectional analyses adjusting for lifetime experience of neglect, lifetime experience of abuse was associated with DNAm for four cytosine-phosphodiester-guanine (CpG) sites (cg20241299: coefficient = 0.023, SE = 0.004; cg08671764: coefficient = 0.018, SE = 0.003; cg27152686: coefficient = - 0.069, SE = 0.012; cg24241897: coefficient = - 0.003, SE = 0.001; FDR < .05). In longitudinal analyses, experiencing neglect over follow-up was associated with an increase in DNAm for one CpG site, adjusting for abuse over follow-up (cg03135983: coefficient = 0.036, SE = 0.006; FDR < .05).

CONCLUSIONS

In this study, we identified examples of epigenetic patterns associated with ELA experiences of threat and deprivation that were already observable in youth. We provide novel evidence for change in DNAm over time in relation to ongoing adversity and that experiences reflecting distinct ELA dimensions may be characterized by unique epigenetic patterns.

The association of posttraumatic stress disorder, depression, and head injury with mid-life cognitive function in civilian women

BACKGROUND

Despite evidence linking posttraumatic stress disorder (PTSD), depression, and head injury, separately, with worse cognitive performance, investigations of their combined effects on cognition are limited in civilian women.

METHODS

The Cogstate Brief Battery assessment was administered in 10,681 women from the Nurses' Health Study II cohort, mean age 64.9 years (SD = 4.6). Psychological trauma, PTSD, depression, and head injury were assessed using online questionnaires. In this cross-sectional analysis, we used linear regression models to estimate mean differences in cognition by PTSD/depression status and stratified by history of head injury.

RESULTS

History of head injury was prevalent (36%), and significantly more prevalent among women with PTSD and depression (57% of women with PTSD and depression, 21% of women with no psychological trauma or depression). Compared to having no psychological trauma or depression, having combined PTSD and depression was associated with worse performance on psychomotor speed/attention ( β  = -.15, p = .001) and learning/working memory ( β  = -.15, p < .001). The joint association of PTSD and depression on worse cognitive function was strongest among women with past head injury, particularly among those with multiple head injuries.

CONCLUSIONS

Head injury, like PTSD and depression, was highly prevalent in this sample of civilian women. In combination, these factors were associated with poorer performance on cognitive tasks, a possible marker of future cognitive health. Head injury should be further explored in future studies of PTSD, depression and cognition in women.

Sexual Violence and Risk of Hypertension in Women in the Nurses' Health Study II: A 7-Year Prospective Analysis

Background Hypertension is a prevalent condition in women and an important modifiable risk factor for cardiovascular disease. Despite women's experiences of sexual violence being common, no prospective studies have examined lifetime sexual assault and workplace sexual harassment in relationship to hypertension in large civilian samples with extended follow-up. Here, we examined whether these experiences were prospectively associated with greater risk of developing hypertension over 7 years. Methods and Results Data are from a substudy of the Nurses' Health Study II and include women free of hypertension at the time of sexual assault and workplace sexual harassment assessment in 2008 (n=33 127). Hypertension was defined as self-reported doctor diagnosis or initiating antihypertensive medication use, assessed biennially through 2015. We performed Cox proportional hazards regression models to predict time to developing hypertension associated with sexual violence exposure, adjusting for relevant covariates. Over follow-up, 7096 women developed hypertension. Sexual assault and workplace sexual harassment were prevalent (23% and 12%, respectively; 6% of women experienced both). Compared with women with no exposure, women who experienced both sexual assault and workplace sexual harassment had the highest risk of developing hypertension (hazard ratio [HR], 1.21; 95% CI, 1.09-1.35), followed by women who experienced workplace sexual harassment (HR, 1.15; 95% CI, 1.05-1.25) and then by women who experienced sexual assault (HR, 1.11; 95% CI, 1.03-1.19), after adjusting for relevant covariates. Conclusions Sexual assault and workplace sexual harassment are prospectively associated with greater risk of hypertension. Reducing such violence is important in its own right and may also improve women's cardiovascular health.

Childhood Abuse and Cognitive Function in a Large Cohort of Middle-Aged Women

Cognitive function at middle age is of particular public health interest, as it strongly predicts later dementia. Children who have experienced abuse subsequently have worse cognitive function than those who have not. However, it remains unclear whether the association of abuse with cognitive function persists into middle age. In 2014-2016, 14,151 women ages 49-69 years who had previously responded to a childhood abuse questionnaire completed a cognitive battery. In models adjusted for childhood socioeconomic status and head trauma, combined physical, emotional, and sexual abuse was associated with lower scores on both Learning/Working Memory (severe abuse, lower scores similar to that observed in women 4.8 years older in our data) and Psychomotor Speed/Attention (severe abuse, lower scores similar to that observed in women to 2.9 years older in our data). Adjustment for adulthood socioeconomic status and health factors (e.g., smoking, hypertension) slightly attenuated associations. In exploratory analyses further adjusted for psychological distress, associations were attenuated. Women exposed versus unexposed to childhood abuse had poorer cognitive function at mid-life. Associations were particularly strong for learning and working memory and were not accounted for by adulthood health factors. Childhood abuse should be investigated as a potential risk factor for cognitive decline and dementia in old age.

Elucidating posttraumatic stress symptom dimensions and health correlates among postpartum women

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with interpersonal dysfunction and adverse maternal health during the perinatal period (extending from conception through one year postpartum). However, PTSD is a heterogeneous disorder, and little is known about which aspects of this disorder may be particularly deleterious to the health of new mothers. Such data may inform more personalized approaches to PTSD prevention and treatment among postpartum women.

METHODS

Using confirmatory factor analysis, we compared three models of PTSD symptom structure-the four-factor dysphoria model, four-factor emotional numbing model, and five-factor dysphoric arousal model-in 1,663 postpartum women from the Community and Child Health Network (CCHN). We examined associations between PTSD symptom dimensions of the best-fitting model with four correlates relevant to maternal health and functioning-parenting stress, partner relationship stress, relationship satisfaction, and contraceptive use.

RESULTS

Though all models fit well, the five-factor dysphoric arousal model provided optimal fit. Symptom dimensions from this model-re-experiencing, avoidance, numbing, dysphoric arousal, and anxious arousal-evidenced differential associations with the maternal health indicators. Numbing symptoms were most strongly associated with indicators of poor interpersonal functioning, whereas dysphoric arousal symptoms were most strongly related to low-efficacy contraceptive use.

LIMITATIONS

Our cross-sectional study assessed DSM-IV PTSD symptoms.

CONCLUSIONS

PTSD symptoms among postpartum women are best-represented by five factors. Numbing symptoms (e.g., restricted affect, detachment) are most strongly associated with interpersonal difficulties, whereas dysphoric arousal symptoms (e.g., agitation, irritability) are linked with low-efficacy contraceptive use. Screening for these symptoms may help promote the health of new mothers.

Disentangling sex differences in the shared genetic architecture of posttraumatic stress disorder, traumatic experiences, and social support with body size and composition

There is a well-known association of traumatic experiences and posttraumatic stress disorder (PTSD) with body size and composition, including consistent differences between sexes. However, the biology underlying these associations is unclear. To understand the genetic underpinnings of this complex relationship, we investigated genome-wide datasets informative of African and European ancestries from the Psychiatric Genomic Consortium, the UK Biobank, the GIANT Consortium, and the Million Veteran Program. We used genome-wide association statistics to estimate sex-specific genetic correlations (r g ) of traumatic experiences, social support, and PTSD with multiple anthropometric traits. After multiple testing corrections (false discovery rate, FDR q < 0.05), we observed 58 significant r g relationships in females (e.g., childhood physical abuse and body mass index, BMI r g  = 0.245, p = 3.88 × 10-10) and 21 significant r g relationships in males (e.g., been involved in combat or exposed to warzone and leg fat percentage; r g  = 0.405, p = 4.42 × 10-10). We performed causal inference analyses of these genetic overlaps using Mendelian randomization and latent causal variable approaches. Multiple female-specific putative causal relationships were observed linking body composition/size with PTSD (e.g., leg fat percentage→PTSD; beta = 0.319, p = 3.13 × 10-9), traumatic experiences (e.g., childhood physical abuse→waist circumference; beta = 0.055, p = 5.07 × 10-4), and childhood neglect (e.g., "someone to take you to doctor when needed as a child"→BMI; beta = -0.594, p = 1.09 × 10-5). In males, we observed putative causal effects linking anthropometric-trait genetic liabilities to traumatic experiences (e.g., BMI→childhood physical abuse; beta = 0.028, p = 8.19 × 10-3). Some of these findings were replicated in individuals of African descent although the limited sample size available did not permit us to conduct a sex-stratified analysis in this ancestry group. In conclusion, our findings provide insights regarding sex-specific causal networks linking anthropometric traits to PTSD, traumatic experiences, and social support.

Associations of trauma and posttraumatic stress disorder with aldosterone in women

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with increased cardiovascular risk, however, underlying mechanisms have not been fully specified. PTSD is associated with stress-related hormones, including dysregulated glucocorticoid activity. Dysregulation of aldosterone, a mineralocorticoid activated by psychological stress and implicated in cardiovascular damage, may be a relevant pathway linking PTSD and cardiovascular risk. Few studies to date have evaluated the association between PTSD and aldosterone, none with repeated measures of aldosterone. We examined if trauma and PTSD were associated with altered aldosterone levels relative to women unexposed to trauma.

METHODS

The association of trauma exposure and chronic PTSD with plasma aldosterone levels was investigated in 521 middle-aged women in the Nurses' Health Study II. Aldosterone was assessed at two time points, 10-16 years apart, and trauma exposure and PTSD were also ascertained for both time points. Regarding exposure assessment, women were characterized based on a structured diagnostic interview as: having chronic PTSD (PTSD at both time points; n = 174); being trauma-exposed (trauma exposure at first time point but no PTSD; n = 174); and being unexposed (no trauma exposure at either time point; reference group for all analyses; n = 173). Linear mixed models examined associations of trauma and PTSD status with log-transformed aldosterone levels, adjusting for covariates and health-related variables that may confound or lie on the pathway between PTSD and altered aldosterone levels.

RESULTS

Across the sample, mean aldosterone concentration decreased over time. Adjusting for covariates, women with chronic PTSD had significantly lower aldosterone levels averaged over time, compared to women unexposed to trauma (β = - 0.08, p = 0.04). Interactions between trauma/PTSD group and time were not significant, indicating change in aldosterone over time did not differ by trauma/PTSD status. Post-hoc exploratory analyses suggested that menopausal status partially mediated the relationship between chronic PTSD status and aldosterone level, such that postmenopausal status explained 7% of the effect of PTSD on aldosterone.

CONCLUSIONS

These findings indicate that PTSD is associated with lower levels of aldosterone. Further work is needed to understand implications of this type of dysregulation in a key biological stress system for cardiovascular and other health outcomes previously linked with PTSD.

Military Sexual Trauma and Adverse Mental and Physical Health and Clinical Comorbidity in Women Veterans

INTRODUCTION

Military sexual trauma (MST)-exposure to sexual harassment or assault during military service-is a major health priority for the Veterans Health Administration (VHA). We examined the health correlates of MST in the largest sample of U.S. women veterans studied to date.

METHODS

Using national VHA electronic medical record data, we identified 502,199 women veterans who enrolled in the VHA between January 1, 2000, and December 31, 2017, had at least one VHA visit, and were screened for MST (exclusive of those who declined to answer the screening). We conducted logistic regression analyses to examine associations of a positive MST screen with various mental and physical health conditions-defined by administrative diagnostic codes-and comorbidity of mental and/or physical health conditions. Models were adjusted for demographic and military service characteristics, along with duration in the VHA.

RESULTS

Approximately 26% (n = 130,738) of women veterans screened positive for MST. In fully adjusted models, a positive MST screen was associated with greater risk of having all mental and physical health conditions examined, except cancer-related conditions, ranging from 9% greater odds of rheumatic disease to 5.4 times greater odds of post-traumatic stress disorder. MST was also associated with greater comorbidity, including greater odds of having ≥2 mental health conditions (odds ratio [OR], 3.28; 99% confidence interval [CI], 3.20-3.37), having ≥2 physical health conditions (OR, 1.26; 99% CI, 1.22-1.29), and having ≥1 mental health condition and ≥1 physical health condition (OR, 2.05; 99% CI, 2.00-2.11).

CONCLUSIONS

Findings suggest that MST is common in women veterans and may play a role in the clinical complexity arising from comorbid conditions.

Association of COVID-19 transmission with high levels of ambient pollutants: Initiation and impact of the inflammatory response on cardiopulmonary disease

Ambient air pollution contributes to 7 million premature deaths annually. Concurrently, the ongoing coronavirus disease 2019 (COVID-19) pandemic, complicated with S-protein mutations and other variants, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in over 2.5 million deaths globally. Chronic air pollution-mediated cardiopulmonary diseases have been associated with an increased incidence of hospitalization and mechanical ventilation following COVID-19 transmission. While the underlying mechanisms responsible for this association remain elusive, air pollutant-induced vascular oxidative stress and inflammatory responses have been implicated in amplifying COVID-19-mediated cytokine release and vascular thrombosis. In addition, prolonged exposure to certain types of particulate matter (PM2.5, d < 2.5 μm) has also been correlated with increased lung epithelial and vascular endothelial expression of the angiotensin-converting enzyme-2 (ACE2) receptors to which the SARS-CoV-2 spike glycoproteins (S) bind for fusion and internalization into host cells. Emerging literature has linked high rates of SARS-CoV-2 infection to regions with elevated levels of PM2.5, suggesting that COVID-19 lockdowns have been implicated in regional reductions in air pollutant-mediated cardiopulmonary effects. Taken together, an increased incidence of SARS-CoV-2-mediated cardiopulmonary diseases seems to overlap with highly polluted regions. To this end, we will review the redox-active components of air pollutants, the pathophysiology of SARS-CoV-2 transmission, and the key oxidative mechanisms and ACE2 overexpression underlying air pollution-exacerbated SARS-CoV-2 transmission.

Examining Individual and Synergistic Contributions of PTSD and Genetics to Blood Pressure: A Trans-Ethnic Meta-Analysis

Growing research suggests that posttraumatic stress disorder (PTSD) may be a risk factor for poor cardiovascular health, and yet our understanding of who might be at greatest risk of adverse cardiovascular outcomes after trauma is limited. In this study, we conducted the first examination of the individual and synergistic contributions of PTSD symptoms and blood pressure genetics to continuous blood pressure levels. We harnessed the power of the Psychiatric Genomics Consortium-PTSD Physical Health Working Group and investigated these associations across 11 studies of 72,224 trauma-exposed individuals of European (n = 70,870) and African (n = 1,354) ancestry. Genetic contributions to blood pressure were modeled via polygenic scores (PGS) for systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were derived from a prior trans-ethnic blood pressure genome-wide association study (GWAS). Results of trans-ethnic meta-analyses revealed significant main effects of the PGS on blood pressure levels [SBP: β = 2.83, standard error (SE) = 0.06, p < 1E-20; DBP: β = 1.32, SE = 0.04, p < 1E-20]. Significant main effects of PTSD symptoms were also detected for SBP and DBP in trans-ethnic meta-analyses, though there was significant heterogeneity in these results. When including data from the largest contributing study - United Kingdom Biobank - PTSD symptoms were negatively associated with SBP levels (β = -1.46, SE = 0.44, p = 9.8E-4) and positively associated with DBP levels (β = 0.70, SE = 0.26, p = 8.1E-3). However, when excluding the United Kingdom Biobank cohort in trans-ethnic meta-analyses, there was a nominally significant positive association between PTSD symptoms and SBP levels (β = 2.81, SE = 1.13, p = 0.01); no significant association was observed for DBP (β = 0.43, SE = 0.78, p = 0.58). Blood pressure PGS did not significantly moderate the associations between PTSD symptoms and blood pressure levels in meta-analyses. Additional research is needed to better understand the extent to which PTSD is associated with high blood pressure and how genetic as well as contextual factors may play a role in influencing cardiovascular risk.

Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans

Importance

Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking.

Objective

To determine whether PTSD is associated with incident IHD in women veterans.

Design, Setting, and Participants

In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020.

Exposures

PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters.

Main Outcomes and Measures

Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes.

Results

A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38).

Conclusions and Relevance

This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.

Hyperarousal Symptoms in Survivors of Cardiac Arrest Are Associated With 13 Month Risk of Major Adverse Cardiovascular Events and All-Cause Mortality

BACKGROUND

Key dimensions of cardiac arrest-induced posttraumatic stress disorder (PTSD) symptoms include reexperiencing, avoidance, numbing, and hyperarousal. It remains unknown which dimensions are most predictive of outcome.

PURPOSE

To determine which dimensions of cardiac arrest-induced PTSD are predictive of clinical outcome within 13 months posthospital discharge.

METHODS

PTSD symptoms were assessed in survivors of cardiac arrest who were able to complete psychological screening measures at hospital discharge via the PTSD Checklist-Specific scale, which queries for 17 symptoms using five levels of severity. Responses on items for each symptom dimension of the four-factor numbing model (reexperiencing, avoidance, numbing, and hyperarousal) were converted to Z-scores and treated as continuous predictors. The combined primary endpoint was all-cause mortality (ACM) or major adverse cardiovascular events (MACE; hospitalization for myocardial infarction, unstable angina, heart failure, emergency coronary revascularization, or urgent defibrillator/pacemaker placements) within 13 months postdischarge. Four bivariate Cox proportional hazards survival models evaluated associations between individual symptom dimensions and ACM/MACE. A multivariable model then evaluated whether significant bivariate predictors remained independent predictors of the primary outcome after adjusting for age, sex, comorbidities, premorbid psychiatric diagnoses, and initial cardiac rhythm.

RESULTS

A total of 114 patients (59.6% men, 52.6% white, mean age: 54.6 ± 13 years) were included. In bivariate analyses, only hyperarousal was significantly associated with ACM/MACE. In a fully adjusted model, 1 standard deviation increase in hyperarousal symptoms corresponded to a two-times increased risk of experiencing ACM/MACE.

CONCLUSIONS

Greater level of hyperarousal symptoms was associated with a higher risk of ACM/MACE within 13 months postcardiac arrest. This initial evidence should be further investigated in a larger sample.

Key dimensions of post-traumatic stress disorder and endothelial dysfunction: a protocol for a mechanism-focused cohort study

INTRODUCTION

Both trauma exposure and post-traumatic stress disorder (PTSD) are associated with increased risk of cardiovascular disease (CVD), the leading cause of death in the USA. Endothelial dysfunction, a modifiable, early marker of CVD risk, may represent a physiological mechanism underlying this association. This mechanism-focused cohort study aims to investigate the relationship between PTSD (both in terms of diagnosis and underlying symptom dimensions) and endothelial dysfunction in a diverse, community-based sample of adult men and women.

METHODS AND ANALYSIS

Using a cohort design, 160 trauma-exposed participants without a history of CVD are designated to the PTSD group (n=80) or trauma-exposed matched control group (n=80) after a baseline diagnostic interview assessment. Participants in the PTSD group have a current (past month) diagnosis of PTSD, whereas those in the control group have a history of trauma but no current or past psychiatric diagnoses. Endothelial dysfunction is assessed via flow-mediated vasodilation of the brachial artery and circulating levels of endothelial cell-derived microparticles. Two higher order symptom dimensions of PTSD-fear and dysphoria-are measured objectively with a fear conditioning paradigm and attention allocation task, respectively. Autonomic imbalance, inflammation, and oxidative stress are additionally assessed and will be examined as potential pathway variables linking PTSD and its dimensions with endothelial dysfunction. Participants are invited to return for a 2-year follow-up visit to reassess PTSD and its dimensions and endothelial dysfunction in order to investigate longitudinal associations.

ETHICS AND DISSEMINATION

This study is conducted in compliance with the Helsinki Declaration and University of California, Los Angeles Institutional Review Board. The results of this study will be disseminated via articles in peer-reviewed journals and presentations at academic conferences and to community partners.

TRIAL REGISTRATION NUMBER

NCT03778307; pre-results.

Racial and ethnic disparities in posttraumatic psychopathology among postpartum women

People of color in the United States disproportionately bear the burden of trauma and posttraumatic stress disorder (PTSD). Pregnant women of color are at particular risk, as perinatal PTSD is associated with adverse maternal and child health. However, PTSD is a heterogeneous disorder comprising discrete symptom dimensions. Adopting a dimensional understanding of PTSD could aid in identifying women at-risk for the consequences of posttraumatic psychopathology and guide treatment selection. In a large sample of Latina, Black, and non-Hispanic White postpartum women in the United States (N = 1663), we examined racial and ethnic differences in the factors of the dysphoric arousal model-a leading dimensional model of PTSD. This model is characterized by five symptom dimensions: re-experiencing, avoidance, numbing, dysphoric arousal, and anxious arousal. Past-year trauma in this sample was common, afflicting nearly 70% of women. In unadjusted models, women of color exhibited more severe PTSD symptom levels across dimensions except for dysphoric arousal, with Black mothers particularly affected. In models adjusted for age, education, and poverty, Black women continued to report elevated symptoms of avoidance and, relative to Latina mothers, re-experiencing symptoms. In contrast, White women reported more dysphoric arousal symptoms relative to women of color. Illuminating differential patterns of symptom dimensions across racial and ethnic groups is critical to PTSD assessment and treatment and may shed light on disparities. Perinatal healthcare may be an important opportunity for posttraumatic symptom screening, and greater understanding of racial and ethnic variation in posttraumatic symptom dimensions can guide targeted intervention selection for perinatal women.

Dissecting the genetic association of C-reactive protein with PTSD, traumatic events, and social support

Inflammatory markers like C-reactive protein (CRP) have been associated with post-traumatic stress disorder (PTSD) and traumatic experiences, but the underlying mechanisms are unclear. We investigated the relationship among serum CRP, PTSD, and traits related to traumatic events and social support using genetic association data from the Psychiatric Genomics Consortium (23,185 PTSD cases and 151,309 controls), the UK Biobank (UKB; up to 117,900 individuals), and the CHARGE study (Cohorts for Heart and Aging Research in Genomic Epidemiology, 148,164 individual). Linkage disequilibrium score regression, polygenic risk scoring, and two-sample Mendelian randomization (MR) analyses were used to investigate genetic overlap and causal relationships. Genetic correlations of CRP were observed with PTSD (rg = 0.16, p = 0.026) and traits related to traumatic events, and the presence of social support (-0.28 < rg < 0.20; p < 0.008). We observed a bidirectional association between CRP and PTSD (CRP → PTSD: β = 0.065, p = 0.015; PTSD → CRP: β = 0.008, p = 0.009). CRP also showed a negative association with the "felt loved as a child" trait (UKB, β = -0.017, p = 0.008). Owing to the known association of socioeconomic status (SES) on PTSD, a multivariable MR was performed to investigate SES as potential mediator. We found that household income (univariate MR: β = -0.22, p = 1.57 × 10-7; multivariate MR: β = -0.17, p = 0.005) and deprivation index (univariate MR: β = 0.38, p = 1.63 × 10-9; multivariate MR: β = 0.27, p = 0.016) were driving the causal estimates of "felt loved as a child" and CRP on PTSD. The present findings highlight a bidirectional genetic association between PTSD and CRP, also suggesting a potential role of SES in the interplay between childhood support and inflammatory processes with respect to PTSD risk.

Unspecified stress disorders and risk of arterial and venous thromboembolic disease in the Danish population

BACKGROUND

Posttraumatic stress disorder is a well-documented risk factor for cardiovascular disease. Whether non-specific stress-related psychopathology also increases risk is less well known.

METHODS

In a cohort of adult Danish-born residents of Denmark with an incident diagnosis of unspecified reaction to severe stress ("unspecified stress reaction") between 1995 and 2011 (N = 24,534), we assessed incidence of seven arterial and venous cardiovascular events/conditions between 1996 and 2013. We calculated standardized incidence ratios (SIRs) comparing incidence of each outcome among the cohort to expected incidence based on sex-, age-, and calendar-time-specific national rates. We conducted stratified analyses by demographic characteristics, comorbidities, and length of follow-up time.

RESULTS

Incidence over the study period ranged from 1.1% for provoked VTE to 5.7% for stroke, adjusting for competing risk of death. Unspecified stress reaction was associated with all outcomes (SIRs ranging from 1.3, 95% confidence interval (CI): 1.1-1.4 for atrial fibrillation/flutter to 1.9, 95% CI: 1.7-2.2 for unprovoked VTE and 1.9, 95% CI: 1.6-2.3 for provoked VTE). Associations persisted, but were attenuated, when restricting to persons without alcohol use disorder and to persons without physical health comorbidities.

LIMITATIONS

Unspecified stress reaction has less precise criteria than other stress-related diagnoses, and we could not adjust for some potential confounders.

CONCLUSIONS

Our results augment literature on stress disorders and cardiovascular disease by highlighting the additional importance of unspecified stress disorders. Further research on this diagnostic category, which may represent subsyndromal psychopathology, is warranted. These findings support considering persons with non-specific stress-related psychopathology in treatment and tertiary prevention activities.