Haunted by the Past: Adverse Childhood Experiences and RA

Margaret Port, MA

Since the results of the groundbreaking CDC-Kaiser ACE study were released in 1998 (Felitti et al.), the detrimental effects of adverse childhood experiences (ACEs) have become better documented. ACEs are defined as potentially traumatic events that occur before adulthood. The original study reported that more than half of participants reported at least one ACE. The research team observed a direct correlation between the number of ACEs experienced and the likelihood of developing mental and physical illness.

Research has also explored the relationship between ACEs and rheumatoid arthritis (RA) and other chronic inflammatory diseases. That research suggests that adults who experienced 2 or more traumatic events during childhood are at a 100% increased risk to develop rheumatic disease (Dube et al., 2009). Of course, patients with RA are then particularly vulnerable to further exploitation. In this way, while trauma may contribute to the development of inflammatory disease, it may be an unexpected consequenceof the disease as well.

So why does this matter in medical practice? In addition to the general importance of understanding of your patients’ histories, an unaddressed childhood trauma history can negatively impact a patient’s response to RA treatment. This may be particularly relevant for patients who appear non-compliant or resistant to treatment.

Rheumatologists, who have long-term working relationships with their patients, are uniquely situated to use trauma-informed daily practices. The first step is to determine HOW you want to assess your patient’s history. Some providers use measures specifically designed to assess trauma history (eg, Life Events Checklist and the Adverse Childhood Experience Questionnaire). Those measures are sometimes embedded in intake paperwork, but your patients may not feel comfortable disclosing their trauma history during that initial meeting. In fact, patients may be hesitant to share this information because they feel guilty or shameful. With this in mind, consider instead leaving room for the conversation in every meeting with your patients. Shifting your inquiry towards “what have you experienced?” and away from “what is wrong with you?” can actually yield considerable information.

The second and perhaps most important consideration is when to make a referral for psychological or behavioral health care. If your patient’s responses on the instruments or interview suggest a history of trauma and they exhibit signs to suggest that trauma is affecting their case, you can make that referral. Classic signs that someone needs a referral to a mental health provider include any indication that the patient is being exploited but also complaints of sleep or mood disturbance, reports that intrusive thoughts are affecting their work or family responsibilities, or the report of other unhealthy or self-destructive behaviors such as overeating or substance use. You may notice changes in attendance (frequently cancelled or skipped appointments) or in treatment compliance.

If you are working in an integrated practice, you can make a referral to your behavioral health colleagues, but you can also curate a list of trusted local licensed mental health or psychiatric providers. The International Society for the Study of Trauma and Dissociation has a searchable database and Psychology Today allows you to search for behavioral health providers who are certified in trauma-related approached like Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Processing Therapy (CPT), or Prolonged Exposure Therapy (PET). Patients who need and receive treatment for trauma are less likely to avoid care and jeopardize their health and are more likely to benefit from treatment and have positive outcomes,including reductions in physical pain. Recognizing that childhood trauma is an important aspect of each patient’s clinical presentation and utilizing the expertise of your network of mental health provider colleagues are 2 cornerstones of a trauma-informed rheumatology practice.

References:

Dube, S. R., Fairweather, D., Pearson, W. S., Felitti, V. J., Anda, R. F., & Croft, J. B. (2009). Cumulative childhood stress and autoimmune diseases in adults. Psychosomatic medicine, 71(2), 243.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.