Post-Traumatic Stress Disorder is Associated With Poor Health Behaviors: Findings From the Heart and Soul Study

Though posttraumatic stress disorder (PTSD) is an illness commonly known for its impact on mental health, it is increasingly recognized as a disorder that is associated with poor physical health as well (Heppner et al., 2009; Hoge et al., 2004; Kessler, 2000; Kross, Gries, & Curtis, 2008). Veterans with PTSD have been found to have a higher lifetime prevalence of circulatory, digestive, musculoskeletal, nervous system, respiratory and infectious diseases (Boscarino, 1996; Andersen, Wade, Possemato, Ouimette, 2010). In particular, PTSD has been shown to be a major risk factor for cardiovascular disease (CVD), with studies finding that patients with PTSD are at increased risk of myocardial infarction and CVD death (Boscarino, 2006; Kang, Bullman, & Taylor, 2006; Kubzansky, Koenen, Jones, & Eaton, 2009; Kubzansky, Koenen, Spiro, Vokonas, & Sparrow, 2007). PTSD can impact physical health through several potential pathways. Schnurr and Green (2004) have created a conceptual framework describing psychological, biological, behavioral, and attentional mechanisms by which PTSD might lead to adverse physical health outcomes. The psychological effects of PTSD include dissociation and the development of avoidant coping strategies, which may result in delayed seeking of health care. PTSD might also act via biological mechanisms, leading to physiological changes such as excess sympathetic activity and disruption of the hypothalamic-pituitary-adrenal axis that may directly damage the cardiovascular system and cause atherosclerosis (Kubzansky & Koenen, 2009; McEwen, 2003). This study focuses on the association between PTSD and health behaviors, which plays a particularly important role in the development and progression of CVD (Whooley et al., 2008). For example, lower physical activity is one of the strongest predictors of future CVD events and death in patients with existing heart disease (Lavie, Thomas, Squires, Allison, & Milani, 2009). Medication adherence is critical for control of CVD risk factors, such as diabetes, high blood pressure, and dyslipidemia, and nonadherence predicts cardiovascular events (Gehi, Ali, Na, & Whooley, 2007). Finally, smoking causes CVD events through atherosclerosis of the coronary arteries, dyslipidemia, and increased thrombosis. Several studies have demonstrated that patients with PTSD have increased rates of tobacco and illicit substance use, but other health behaviors have received less attention (Feldner, Babson, & Zvolensky, 2007; Jacobsen, Southwick, & Kosten, 2001). Few studies have looked at exercise patterns in patients with PTSD. Those that have been published did not compare physical activity habits of patients with PTSD to a control sample without PTSD and/or had a sample size too small to draw conclusions about the association between PTSD and exercise (Buckley, Mozley, Bedard, Dewulf, & Greif, 2004; de Assis et al., 2008). Medication adherence may also be lower in PTSD, but this has only been studied in pediatric transplant patients and patients with recent myocardial infarction (Shemesh et al., 2001; Shemesh et al., 2004). In addition, the association of PTSD with these health behaviors has not been examined in patients with stable CVD, a population at highest risk for future CVD events. In this study, data was collected from a diverse cohort of 1,022 patients with stable CVD to investigate the association of PTSD with physical activity, medication adherence, and smoking. The hypothesis was that PTSD would be associated with a higher incidence of poor health behaviors. Understanding the association of PTSD and health behaviors can lead to new avenues to reduce CVD morbidity and mortality and improve the long-term health of the growing number of individuals living with PTSD.