Propuesta analítica de regímenes híbridos

In addition to increased reporting of symptoms and increased use of medical services, victims of trauma also experience increased morbidity and mortality rates.⁵⁵ Studies have tended to focus on war-related trauma, with many of them addressing health status of former prisoners of war (POWs).^56,57Many of these former POWs experienced increased gastrointestinal and cardiovascular complaints and illnesses, especially peptic ulcer disease, hypertension, and

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cardial infarction. In addition, increased mortality was noted in these POWs, especially in the areas of accidents, suicide, and cirrhosis of the liver.⁵⁸These mortality statistics, of course, could be related to the emotional sequelae of war trauma, and the associated increased incidence of alcohol abuse. Cardiovascular morbidity and mortality, however, appear to be more specific complications of wartime stress as documented in the above studies, and in studies of residents of Lebanon and Croatia during civil wars in those countries.^59,60 In cases of childhood abuse, however, the literature is less clear regard-ing increased incidence of disease processes in adulthood. Most of the problems experienced in adult survivors of child abuse seem to fall into the classification of functional diseases rather than objective organic disease.⁵³Felitti and colleagues, however, have recently doc-umented a strong graded relationship between the degree and sever-ity of exposure to abuse or dysfunctional family behavior patterns during childhood and a number of the leading causes of death during adulthood.⁶¹ This study provides convincing evidence for the dan-gers of unresolved traumatic stress to one’s health and life, especially trauma experienced during childhood.

When the clinical diagnosis of PTSD is added to the equation, how-ever, the incidence and significance of adverse health effects of trauma increases significantly.^55,62The greatest area of vulnerability probably involves the cardiovascular system,^63,64a predictable association consid-ering the cardiovascular effects of the stress and fight/flight responses.

Specific studies of the cardiovascular effects of sympathetic auto-nomic dysregulation in primates certainly support the concept of a role of stress in the development of atherosclerotic cardiovascular disease.⁶⁵

In their review of the relationship between stress, PTSD, and health, Friedman and Schnurr hypothesize that the widespread changes induced by the neurochemical substrate of PTSD have significant ad-verse health effects.⁵⁵Hypertension and atherosclerotic cardiovascu-lar disease are likely among the most common and obvious effects of autonomic dysregulation. Endocrinological abnormalities, especially HPA dysregulation and altered thyroid function, not only may lead to specific endocrine disturbances, but also to immune disorders. Sup-pression of the immune system by initial HPA activation and hyper-cortisolemia might increase susceptibility to infection, as noted earlier in this chapter. Conversely, lowered serum cortisol levels

docu-mented in chronic, late stage PTSD might be expected to produce increased immune activation. Alteration in the genetic phenotypes of blood lymphocytes in PTSD indeed suggests the potentiation of increased immune activation.⁶⁶ Other authors have also postulated that immune dysregulation might also predispose PTSD victims to autoimmune disorders.⁵⁵

CONCLUSION

Although much of the scientific data associating traumatic stress with adverse health effects is circumstantial and subject to debate and interpretation, many studies show physiological alterations in PTSD that correlate with predictable diseases seen in its victims. There also appears to be a small cluster of poorly understood syndromes that have a compelling link to the physiology and incidence of trauma, in-cluding irritable bowel syndrome, interstitial cystitis, chronic pain syndromes, fibromyalgia/CFS, and RSD. Other so-called diseases of stress, including hypertension, peptic ulcer disease, ulcerative colitis, and atherosclerotic coronary artery disease probably also can be added to the list of diseases of trauma. Idiopathic autoimmune syn-dromes need to be considered as well. Because the physiological events associated with stress and trauma are by nature fluctuating and dynamic, consistent measurement of these events in relationship to clinical symptoms or signs remains a challenge. Proof of a direct rela-tionship between trauma and these syndromes therefore is likely to be extremely difficult. The evidence at hand also suggests that stress and trauma alone are often not sufficient to cause these diseases. The physiological event of traumatic stress or freeze/dissociation appears to be an important element in triggering the required pathological events. Since the autonomic nervous system in PTSD may well be as-sociated with the self-perpetuating central nervous system phenome-non of kindling, it is likely that the resulting continuous perturbation of vascular, endocrinological, and immune systems is required to contribute to the development of these diseases of trauma. As dis-eases of kindling, one might expect them to progress in severity in the apparent absence of an ongoing identifiable pathogenic event. The re-markable prevalence of trauma in modern society is amply demon-strated in the PTSD literature. In this model, therefore, the patho-physiological effects of trauma might well provide the major impetus

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to development and perpetuation of many chronic diseases of un-known cause. A more specific rationale for this relationship will be developed in Chapter 8, linking the process of dissociation to patho-logical autonomic dysregulation, leading to regional vasomotor dis-ease in the dissociated end organ.

Finally, the distinction between the “psychological” and physical pathological manifestations of traumatic stress, as suggested in the term “psychosomatic,” needs to be discarded. The pathophysiological, neurobiological, endocrinological, and immunological changes in-duced by trauma form a continuum with the subsequent pathologi-cal somatic manifestations of disease. Based on Weiner’s^67,68 and Grotstein’s⁶⁹ observations, Schore⁷⁰ states: “Weiner’s fundamental understanding that all physical disease represents a disturbance of regulation and Grotstein’s penetrating insight that all psychopath-ology represents disordered self-regulation clearly indicate that a differ-entiation between physical and psychosomatic disease is meaningless and misleading.” The trauma therefore changes the brain, which therefore changes the body.

Chapter 7