Traumas constitute the most difficult experiences in life. Assaults, severe accidents and injuries, natural disasters, life threatening diseases, and the loss of loved ones comprise just some of the most frequent types of traumas. Tragically, traumatic events are also common, with at least half of adults experiencing one or more major traumas according to the best survey research (1).
Although the mental health consequences of trauma and posttraumatic stress are the subject of many movies well-known in U.S. culture (e.g., Born on the 4th of July, Fearless, Manchester by the Sea, Rambo: First Blood, etc.,), the physical health consequences of trauma receive far less attention. Based the latest trauma science (2), however, ignoring these physical consequences of trauma and PTSD represents a grave error with potentially deadly consequences.
Trauma is a mind-body condition, not a mental condition
The official – and oversimplified – narrative about trauma and post-traumatic stress is that they represent intense emotional and behavioral responses to life-threatening events. Acute stress disorder and PTSD in the DSM-5 (the diagnostic manual used by mental health professionals), for example, are diagnosed entirely by emotional and behavioral symptoms such as hypervigilance, anxiety, insomnia, and avoidance of trauma-related situations and stimuli. Yet the rapidly evolving neuroscience on trauma demonstrates unequivocally that the underlying pathophysiology of trauma inside the body is equally profound and potentially even more harmful (3). And among the areas of the body most rapidly and severely affected by trauma is the heart.
Source: Thomas Rutledge
The acute and chronic cardiovascular consequences of trauma
During a life-threatening experience or event, the brain initiates a systemic biochemical process called the fight-or-flight response. Specifically, the hypothalamus and pituitary and adrenal glands – usually abbreviated the HPA axis for short – coordinate to produce a rapid and powerful stress reaction throughout the body using hormones and neurotransmitters. The latter chemicals markedly alter the normal function of the major organs, including the heart.
Although the fight-or-flight response is intended to help a person survive a traumatic event, this same response is sometimes deadly. For example, the incidence of heart attacks and strokes increases substantially during and in the aftermath of natural disasters. Surprisingly, deaths resulting from stress-induced cardiovascular events during natural disasters such as earthquakes often exceed the number of deaths caused by the natural disaster itself (4).
The cardiovascular phenomenon frequently referred to as “broken-heart syndrome” (technically called Takotsubo cardiomyopathy) is an even more famous example of the paradoxically deadly acute effects of trauma on the heart. As illustrated in the left-side of the above figure, intense emotional stress resulting from a traumatic event such as the loss of a loved one can sometimes weaken the heart so severely as to produce a lethal episode of heart failure. For reasons that remain poorly understood, broken-heart syndrome is vastly more common among women (5).
The chronic cardiovascular effects of trauma are also potentially life-threatening. Our flight-or-flight response evolved over millions of years to function as an emergency survival response; the response is present in humans and across the animal kingdom with remarkable biological similarity. Modernity, however, has exposed us to a problem that our ancestors and evolutionary biology rarely encountered: chronic stress. Instead of the historically normal process of HPA axis activation followed by rest and recovery, modern traumas and stressful events frequently result in a fight-or-flight response that may be sustained for months or even years. Considering that our bodies are a type of biological machine, they suffer the same eventual consequences as a car that is constantly driven at maximum speeds. Battered by an unceasing stress response, the heart and cardiovascular system gradually become diseased and dysfunctional, raising the risk of heart attack and stroke over time (right side of above figure).
Source: Thomas Rutledge
Why the trauma-heart relationship is bidirectional
The final important insight about the trauma-heart relationship is that trauma can be both a cause and a consequence of heart problems. Although the laboratory and epidemiological scientific literatures (2) strongly support a connection between trauma symptoms and acute and chronic cardiovascular risk, separate research also shows convincingly that serious cardiovascular events such as heart attacks and strokes frequency cause trauma reactions among survivors (3). Unfortunately, trauma and other emotional responses are often not assessed in emergency rooms or cardiovascular wards where people may be receiving treatment for cardiovascular events, allowing these symptoms to be overlooked or assumed to be transient.
The bidirectional and potentially synergistic relationship between trauma and the heart makes clear that persons experiencing acute or chronic traumatic stress should receive education and treatment to reduce their potential cardiovascular risk. And persons presenting to medical settings with cardiovascular events should be routinely assessed for trauma to identify symptoms that could worsen their prognosis.
Given the still high rates of traumatic events in modern society, a failure to appreciate the cardiovascular consequences of trauma could have serious public health consequences.