What Caught My Eye: Trauma and SLE: Continuing the Discussion on a link between Adverse Experiences and Autoimmune Disease
Tamar Rubinstein, MD
Children's Hospital at Montefiore
Back in July, Jim Jarvis wrote in “What Caught Our Eye” about an association between Adverse Childhood Experiences (ACEs) and autoimmune disease. He pointed out that over the past decade, evidence has amassed linking ACEs (which include trauma, neglect, parental incarceration, food insecurity, and racial discrimination) to poor health and the development of chronic disease. This association is observed across cultures and people that have differed by geography, ethnicity, and even era of time. Many studies have noted a dose response, where more cumulative experiences lead to increasing risk of disease. And as Jim pointed out a few months ago, autoimmune diseases appear to follow the same pattern.
Jim wrote a moving call to arms to the community, pointing out the knowledge gaps that exist. Among the central questions around a link between trauma/ chronic stress and autoimmune disease is the question of whether this a causal relationship. A paper recently accepted to Arthritis & Rheumatology, "Association of trauma and posttraumatic stress disorder with incident systemic lupus erythematosus (SLE) in a longitudinal cohort of women," brings us closer to an answer.
In this study Andrea Roberts and other researchers from Harvard examined data from about 55,000 women from the Nurses’ Health Study. They investigated the risk of incident lupus in women with and without a history of trauma. They found that women who had experienced trauma had greater than two times the risk of developing lupus compared to women who had not experienced trauma. Women with a history of probable PTSD had three times the risk. This relationship persisted after adjusting for certain at-risk health behaviors and characteristics, such as smoking, that might be associated with PTSD and an increased risk of lupus.
Besides being a large longitudinal study, one of the great strengths of this study is the careful way in which the investigators examined the possibility of reverse causality: that lupus may have caused patients to be more susceptible to reporting trauma. They excluded cases where ‘worst trauma’ reported was from illness and they performed multiple sensitivity analyses to try to clarify the direction of causality, including examining whether SLE increased the risk of incident PTSD (which it did not).
While the notion has been widely held that stress plays a role in the development of autoimmune disease and is a trigger for disease flares, the clinical evidence has been sparse. Probably because studies like that of Roberts, et al, are difficult and costly to conduct. While a handful of other studies have reported an association between PTSD and autoimmune disease, none have been this large or have been able to address the direction of causality as convincingly. To date, at least for lupus, this study may provide the strongest evidence that chronic emotional stress can lead to autoimmune disease.
The questions still remain, are childhood-onset lupus and childhood-onset autoimmune disease different? Do early experienced trauma or even inter-generational trauma play a role in disease development and disease outcomes? Do Adverse Childhood Experiences and Adverse Family Experiences impact early-onset autoimmune disease? And most importantly, if so, what can we do about it? Does investing in our children’s mental health and building up their emotional resilience and ability to cope with trauma protect them?
Now that the greater pediatric community is more attuned to ACEs and trauma-informed care, we may be able to begin to look into these questions through large cohorts in a similar way. Over the next several months, the CARRA Mental Health Workgroup and other investigators will be exploring a potential project to look into the impact of trauma/ ACEs in pediatric rheumatology patients. We will be looking toward our patients and families and the larger community for guidance in this. So, if this is a topic that speaks to you, please join us!
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