PTSD and Heart Disease in Veterans: A Conversation with Beth Cohen

Many veterans returning from Iraq and Afghanistan are affected by post-traumatic stress disorder. Over time, the effects may be physical as well as mental. Beth Cohen, MD, a UCSF researcher and physician at the San Francisco VA Medical Center, is exploring a link between PTSD and heart disease.

Here is an interview with Jeff Norris, science writer at UCSF, and Cohen.

Jeff Norris:

Among veterans, injuries you can’t see may be leading to additional, all-too-evident diseases many years down the road.

While better treatment means that more injured servicemen and -women are surviving injuries, what’s less visible are the large number of combat veterans who return with a mental health disorder.

A recent study by UCSF researchers at the San Francisco VA Medical Center of more than 100,000 veterans of conflict in Afghanistan and Iraq found that one-quarter have a mental health diagnosis, and more than half of these veterans have more than one such diagnosis. The most common is post-traumatic stress disorder – PTSD.

While these two long and continuing wars are increasing awareness of the immediate impacts of PTSD, PTSD may also have insidious, long-term impacts on physical as well as mental heath. UCSF researcher Beth Cohen, a physician at the San Francisco VA, now is studying a strongly suspected link between PTSD and heart disease among recently returning veterans, including female veterans.

Cohen is using up-to-date measures to probe more deeply into the link, obtaining baseline data and following the vets over time. Previous studies on vets from earlier wars were conducted long after combat tours were over, but they were provocative.

Beth Cohen:

There were a few large studies: one of Vietnam veterans, one of veterans of earlier wars, that went back and looked at medical records. And this is decades after people served in the war, and compared heart disease and mortality from heart disease in veterans who did and who did not have post-traumatic stress disorder. And the researchers found that veterans with PTSD were at significantly higher risk of both developing heart disease and dying of heart disease.

Jeff Norris:

PTSD is different from garden-variety, chronic stress, and Cohen thinks its impact on the body and on health will prove to be different as well.

Beth Cohen:

It does affect people in very specific ways – more than being stressed – so in order to get diagnosed with PTSD, you actually need symptoms in each of three categories. So one is reexperiencing your traumatic event, and that can be through nightmares or thoughts that suddenly intrude during the day without warning. The second cluster – there’s also avoidance. So avoidance of anything that reminds you of the event or that might trigger a reaction. One thing that veterans bring up also is the coverage of the current war. That’s a big trigger for a lot of veterans. So I have patients who say they can’t watch the news, or patients who have gone to a movie and then seen combat. It’s triggered a lot of bad memories and symptoms. So there are specific symptoms that are different than just being stressed, and this probably has a different effect on the body.

Jeff Norris:

Okay, we have reexperiencing a traumatic event and avoidance. So what’s the third type of symptom of PTSD?

Beth Cohen:

Hyperarousal. And an example of that would be this constant sense that you’re on edge,. And another thing patients often report is hypervigilance. People say that they’re constantly looking over their shoulders, or they can’t sit in a room and not be facing the door because they don’t know who’s going to come in.

Jeff Norris:

That all sounds like it might take its toll on the body, but how exactly? Cohen points out several possible mechanisms.

Beth Cohen:

One of the things we’re interested in – and one of the links potentially between PTSD and heart disease – is that constantly having this activation could have a negative effect on your body. So, for instance, activating that fight-or-flight response, we know that that affects your immune system. We know that that affects the level of stress hormones in your body, and those hormones, in turn, can actually affect things like your body weight or your blood pressure or your tolerance to blood sugar and risk for diabetes. So those are some of the potential mechanisms by which PTSD could cause heart disease.

Jeff Norris:

Cohen’s new study, called Mind Your Heart, will start with lots of baseline data, both from talking with veterans and from biological samples. Over time, Cohen is hopeful that follow-up will enable her and her colleagues to tease out factors that contribute to heart disease in these vets, including factors associated with PTSD.

Beth Cohen:

Because it’s prospective, we can collect exactly the data we want and follow them over time, so we can see if their PTSD symptoms really precede the development of heart disease. And again, we can look at all those potential mechanisms that might link PTSD in heart disease. And we’re most interested in three areas. The biological mechanisms – so things like higher system nervous activity, more inflammation. Behavioral mechanisms – diet, exercise, even sleep can affect the heart. And lastly, what I’d call psychosocial mechanisms – and those would be other mental health conditions. So we know PTSD often travels with depression, for instance, and that’s a heart disease risk factor. Also, we know people who have poor social support and relationship issues are at an increased risk for heart disease, and that might be a big risk for people with PTSD.

Jeff Norris:

So is there any chance that Cohen’s more in-depth study will be unable to verify a link, despite the provocative data from previous studies of veterans of earlier wars?

Beth Cohen:

I would consider it to be more than a hypothesis, and a lot of people who work with veterans consider that to be a health issue, like PTSD – that they do develop a lot more chronic physical illness. I think we would see it as a real phenomenon. But because there isn’t as much prospective data, I think it still is worthwhile, particularly with younger veterans coming back from our new wars, to follow them over time and see if this plays out.