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They say the body remembers what the mind wants to forget. For those who have experienced trauma, not only does the body remember, in some cases it works on making things worse. Such is the situation with trauma and lupus, says a new study published in Arthritis & Rheumatology in October.
The study, titled, “Association of Trauma and Posttraumatic Stress Disorder with Incident Systemic Lupus Erythematosus in a Longitudinal Cohort of Women,” was undertaken at the Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital, Harvard Medical School.1
The study examined whether exposure to trauma and post-traumatic stress disorder (PTSD) are associated with an increased risk of lupus. Andrea L. Roberts, PhD, of the Harvard T.H. Chan School of Public Health at Harvard Medical School in Boston, was lead author on the study. Describing their work in the first longitudinal study to ask this question in a civilian population, she says, “We examined 24 years of follow-up data in 54,763 women in the Nurses’ Health Study. Women were categorized as having no trauma, trauma and no PTSD symptoms, subclinical PTSD (one to three symptoms) or probable PTSD (four to seven symptoms).”
The Autoimmune Connection
Dr. Roberts
“Women who have lupus often report stress as a trigger for flares, which is similar to other autoimmune diseases,” says Dr. Roberts. “And we already know stress has been associated with increases in inflammation. [Because] lupus is an autoimmune condition, anything that triggers the immune system to jump into action is suspicious. There are additional studies showing that PTSD is associated with a later increased risk of other autoimmune diseases like [rheumatoid arthritis] or inflammatory bowel disease and psoriasis.
“In this study, [although] there was no medical diagnosis of PTSD, participants reported symptoms and their experience of trauma. This included questions, such as, ‘Did you lose interest in activities after the traumatic event?’ Those reporting ‘yes’ to four or more questions were likely to have PTSD.
“Seventy-three cases of lupus were identified during follow-up,” Dr. Roberts says. “We found that being exposed to trauma was strongly statistically associated with lupus. It was rather surprising that the effect size was so large: Women exposed to trauma were at an almost three times higher risk of developing lupus than women with no exposure to traumatic events. Lupus does involve some psychological symptoms, such as depression. And although you can have depression as a symptom of lupus, … the thing with PTSD is that it’s related to a traumatic event—you can’t say the traumatic event is caused by lupus.”
Message to Health Professionals
“Clinicians who treat women with lupus should be aware of the psychological symptoms that can accompany the disease and should know if there is trauma in a patient’s past … that may affect the course of the lupus. We know trauma affects health-related behavior. Take smoking, for example. If we know someone’s trauma history and they are smoking as a way of dealing with anxiety, they are self-medicating and may require additional psychological treatment before they can stop smoking. Although you are treating the physical disease, you must take note of any mental health issues and refer these patients for psychological care.
“This type of research is making clinicians more aware of the tight connections between trauma and physical health. [Although] one research paper doesn’t have an enormous impact, it is noteworthy that many different lines of research are saying the same things.”
Karen Costenbader, MD, MPH, professor of medicine at Harvard Medical School in Boston and director of the Lupus Program, was the senior author of the study. She says, “The topic of past trauma often doesn’t emerge in lupus treatment until one, two or even three years into a patient’s care. Asking about trauma when a patient first presents is not a routine part of rheumatologic care. After a patient gets to know a clinician, however, they are more likely to open up. Then they can be referred to a mental health provider.
Dr. Costenbader
“The hormonal and immune system disruptions involved in PTSD are measurable, but we don’t know if or how they trigger lupus,” Dr. Costenbader says. “We do know cortisol dysregulation exists in PTSD patients, and cortisol influences the functioning of the immune system. In people with PTSD, the body is stuck in a state of hyper-vigilance, which can lead to lupus flares. Patients often report, ‘I had a flare because of a traumatic event (e.g., a car accident, a death, etc.).’ Then you add in possible poor self-care, lack of sleep and flashbacks. We need more research into the biologic mechanisms involved. There are many different organ systems involved with autoimmune conditions. Getting to the bottom of how stress affects autoimmunity is the next step.”
Mechanism Remains Unknown
Dr. Bermas
Bonnie Bermas, MD, a rheumatologist at the University of Texas Southwestern Medical Center in Dallas, says, “This is important work, and the findings are extremely interesting, yet not completely surprising. If you care for patients with lupus, they will often pinpoint the origin of the disease to a period of stress.
“I think it would be helpful to extend this study to a patient population we know has a high incidence of PTSD—such as those in the military—and then evaluate the incidence of lupus among that cohort,” she says.
“There is a complicated relationship between stress and the immune system, and we don’t comprehend the mechanism that relates it to lupus. We don’t even have a clear understanding of who gets lupus without PTSD being involved. Other questions [include], ‘Is trauma playing a bigger role than we thought in the development of lupus?’ and, ‘Is trauma affecting the severity of the disease?’”
Reflecting on practical steps doctors might take to help lupus patients with PTSD, Dr. Costenbader says, “Rheumatologists should more proactively screen for trauma, making it clear to patients we’re not just doing paperwork and gathering data. Now that we are aware of the link between past traumatic events and the increased risk of developing lupus, we should sincerely ask—early on—about past trauma. Perhaps letting patients know that a trauma can affect their lupus condition would propel them to open up to their physicians.”
Elizabeth Hofheinz, MPH, MEd, is a freelance medical editor and writer based in the greater New Orleans area.
Reference
- Roberts AL, Malspeis S, Kubzansky LD, et al. Association of trauma and post-traumatic stress disorder with incident systemic lupus erythematosus in a longitudinal cohort of women. Arthritis Rheumatol. 2017 Nov;69(11):2162–2169.
