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Female veterans with posttraumatic stress disorder (PTSD), especially younger women who are non-white, have an increased risk of developing heart disease.

Findings such as these were presented Friday, November 13, through Tuesday, November 17, at the American Heart Association’s Scientific Sessions 2020.

The presenter was Ramin Ebrahimi, MD, professor of medicine at the University of California, Los Angeles, and director of interventional cardiovascular research and co-director of the Cardiac Catheterization Laboratory at the Greater Los Angeles VA (Veterans Affairs) Medical Center.

“Previous research has linked PTSD to higher risks of ischemic heart disease, including heart attacks and heart pain or angina. However, most of those studies have been in men,” Ebrahimi said to the press.

To conduct the study, Ebrahimi evaluated medical records of female veterans cared for at all US Veterans Health Administration centers between 2000 and the end of 2017. The research team identified nearly 130,000 female veterans with PTSD and nearly 260,000 without the mental health condition. They assessed records for annual exams, emergency room visits and other exams/hospitalizations for new diagnoses of coronary artery disease, angina, or heart attacks.

According to Ebrahimi, they found that women with PTSD had a 44% higher risk of developing ischemic heart disease compared to those without PTSD, and the increased risk was more prominent in younger women, especially those younger than 40 years old (72%).

The increased heart disease risk among female veterans with PTSD was also higher in racial and ethnic minorities, including Black women, non-white women from other racial backgrounds and women of Hispanic and Latinx ethnicity, compared with white female veterans.

“Our results suggest that health care professionals should consider more routine and earlier screening for cardiovascular disorders in women with PTSD,” Ebrahimi said.

1. American Heart Association. Women veterans with PTSD have higher rate of heart disease. News release. November 9, 2020. Accessed November 13, 2020. 

https://www.eurekalert.org/pub_releases/2020-11/aha-wvw110220.php

Non-white veteran women of color may be at greater risk of developing heart disease, according to research.  

Female Veterans with PTSD at Higher Risk of Heart Disease

more than half of gay, lesbian, and bisexual individuals who abuse alcohol or tobacco also have a co-occurring psychiatric disorder, whereas only one-third of heterosexual individuals have the same correlation.

“The degree of disparities in alcohol, tobacco and other psychiatric disorders by sexual identity was very surprising,” Rebecca Evans-Polce, assistant research scientist at the University of Michigan School of Nursing and first author of the study, said to the press. “The differences for women are more striking.”

Previous studies have demonstrated that LGBTQ+ individuals are at greater risk for both substance use disorders and psychiatric disorders. Evans-Polce noted that the new study, which gathered data from 35,796 responses from the National Epidemiologic Survey on Alcohol and Related Conditions, is 1 of the few to examine this risk.

An interesting finding of note is the prevalent comorbidities for bisexual women. When compared to heterosexual women, bisexual women were found much more likely to have an anxiety disorder (32.5% bisexual, 16% heterosexual), mood disorder (35% bisexual, 15% heterosexual), and post-traumatic stress disorder (21% bisexual, 6% heterosexual). According to the data, 63% of bisexual women misusing tobacco also had an anxiety disorder, mood disorder, or PTSD. In contrast, only 46% of heterosexual women with a tobacco use disorder also had a psychiatric issue.

Bisexual individuals overall were 4 times more likely to have PTSD than heterosexual individuals.

The reason for this association is unconfirmed, but researchers suspect discrimination and trauma may be to blame. Sexual orientation discrimination, the number of stressful life events, and the number of adverse childhood experiences were strongly associated with greater risk of comorbidities.

Researchers determined that the data demonstrates a need for integrated substance use and mental health prevention and treatment programs, particularly for individuals who identify as sexual minorities. Additionally, more research is needed to comprehend why data repeatedly points to such a high risk for bisexual women.

1. Evans-Polce RJ, Kcomt L, Veliz PT, Boyd CJ, et al. Alcohol, Tobacco, and Comorbid Psychiatric Disorders and Associations With Sexual Identity and Stress-Related Correlates. 

2. University of Michigan. Sexual minorities, especially women, who misuse substances more likely to have psychiatric disorders. News release. 

https://medicalxpress.com/news/2020-11-sexual-minorities-women-misuse-substances.html

Sexual minorities with alcohol and tobacco addictions are at a higher risk for comorbid psychiatric disorders, bisexual women in particular.

LGBTQ+ Individuals who Abuse Substances Are More Likely to Have Psychiatric Disorders

If you were to poll physicians and ask which specialty usually takes the lead in the management of chronic pain, no doubt an overwhelming majority would say anesthesiology, with a smaller number saying neurology and physiatry. However, probably few would say psychiatry.

It is odd considering the recent revision of the 

 by the International Association for the Study of Pain, the leading worldwide organization for medical professionals involved in the field of pain: “Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors.”

 This appears to be almost precisely with what psychiatry deals.

We already know that there is a high degree of comorbidity between 

 with chronic pain and, although it is commonly thought that the mental disorders are always secondary to the pain, research has shown that pain is a common presenting symptom of these disorders.

The papers in this Special Report discuss 2 other problems that frequently occur in those with chronic pain: 

 (PTSD). We have known about the relationship between sleep disorders and chronic pain for years; however, the relationship between pain and PTSD is a more recent finding.

As with depressive and anxiety disorders, it is usually thought that if a sleep disorder is present in a person with chronic pain, the sleep issue is always secondary to the pain. However, this oversimplifies the relationship. The interaction between pain and sleep disorders is often a 2-way street, with each exacerbating the other. Both the pain and the sleep disorder need to be addressed.

Of course, the presence of any type of pain can impair sleep. Patients with peripheral diabetic neuropathic pain often report worse pain in their lower extremities during the night when they are trying to sleep. Those who suffer from complex regional pain syndrome in their lower extremities may complain that it is it painful to have sheets touch their skin due to allodynia, in which stimuli that do not usually cause pain do so. Patients with back pain often report problems with sleep due to pain although, curiously, laying down is the position they usually find most comfortable. In fact, if the pain is worse lying down, it is considered a red flag indicative of serious underlying pathology.

Similarly, disruption in normal sleep cycles can cause pain. More than 45 years ago, research found disruptive sleep in some healthy individuals precipitated the symptoms of fibromyalgia and resulted in widespread pain.

There are few studies on the treatment of comorbid pain and sleep disorders. Although both are commonly treated with medications, there is limited research on using pharmacologic agents when both problems are present. Most of the studies have looked at pregabalin in patients with fibromyalgia.

Opioids and benzodiazepines, medications that are frequently prescribed for patients with chronic pain, may actually exacerbate pain because they can cause hyperalgesia (eg, lower pain threshold). These agents can also exacerbate sleep disorders because of their disruption of normal sleep architecture. Sadly, many lay people and medical professionals mistakenly believe that the sedative side effects of these medications mean they will be beneficial for sleep.

There is much less research on chronic pain and PTSD, although there has been a growing interest in the past few years. 

A limiting factor of the data is that much of the research involves veterans. Due to the nature of our recent wars, many veterans suffer from painful injuries caused by explosions. They frequently suffer from traumatic brain injuries (TBI) of varying severity. In fact, both pain and sleep disorders have both been associated with TBI.

 Of course, few civilians who suffer PTSD have similar experiences, so the role TBI may play in the development of comorbid PTSD and chronic pain remains to be determined. 

In addition, research has shown that PTSD may not only be associated with both pain and sleep disorders, but also play a role in acute pain becoming chronic pain.

Since we have yet to identify a markedly efficacious treatment for PTSD, adding chronic pain as a factor further complicates care decisions. Furthermore, although there has been much speculation as to which factors predispose people to develop PTSD and chronic pain separately, we still have no final answer, and we have limited ability to predict who is at increased likelihood for developing both.

For all 3 problems—PTSD, sleep disorders, and chronic pain—psychologically based therapies appear to be among the most promising treatments. They also do not carry the same risks of exacerbating another condition as do medications.

Since psychiatrists often treat PTSD and even sleep, there is little doubt they will see patients with comorbid chronic pain. Unless psychiatrists also are knowledgeable about pain and its management, we will not be able to provide optimal care for our patients.

 is in private practice in Philadelphia.

This article was originally posted on October 21, 2020, and has since been updated. Scroll down for the 

 of the full print issue in which it appeared. -Ed

The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises.

2. Moldofsky H, Scarisbrick P, England R, et al. Musculoskeletal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and health subjects. 

3. Husak AK, Bair MJ. Chronic pain and sleep disturbances: a pragmatic review of their relationships, comorbidities, and treatments. 

4. Lavigne G, Khoury S, Chauny JM, et al. Pain and sleep in post-concussion/mild traumatic brain injury. 

5. Burns JW, Janssen, Lillis T, et al. The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department. 

Pain may not often be considered within the realm of psychiatry; however, chronic pain's relationships with sleep disorders and PTSD make it an issue psychiatrists can—and should—address.  

Psychiatry’s Role in the Management of Chronic Pain

The US Food and Drug Administration (FDA) granted a De Novo clearance to a prescription Apple watch and iPhone app meant to improve sleep quality for those with nightmare disorders or posttraumatic stress disorder-related nightmares.

 uses the watch’s sensors to track the user’s heart rate and movement as they sleep. A baseline profile is created for the patient within 1 to 2 nights of sleep. In this short time frame, the learning algorithm will spot heart rate of movement abnormalities likely caused by a nightmare. If the app senses a disturbance, the Apple watch will vibrate enough to interrupt the dream, but not enough to fully wake them up and disturb their sleep cycle.

“Sleep is an essential part of a person’s daily routine,” Carlos Peña, PhD, director of the Office of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health, said to the press. “However, certain adults who have a nightmare disorder or who experience nightmares from PTSD are not able to get the rest they need. Today’s authorization offers a new, low-risk treatment option that uses digital technology in an effort to provide temporary relief from sleep disturbance related to nightmares.”

Data submitted to the FDA included information from a 30-day trial of 70 patients who were randomly assigned to receive either the NightWare app or a placebo app with no vibrations. While both groups self-reported improved sleep quality, the benefit was greater for those provided with the Nightware product.

Further trials are being conducted, one of which hopes to include 240 patients from several Department of Veterans Affairs hospitals. It is projected to finish in the second half of 2021.

“NightWare was founded and built to support veterans and active duty service members who have so unselfishly given of themselves to preserve our freedoms, and suffer emotional, physical and mental distress as a consequence of severe nightmares,” NightWare CEO Grady Hannah said in a statement. “Helping our current and past military members and all people with this condition is NightWare’s mission and we are excited to introduce this first and only therapeutic for nightmares. The use of the NightWare Therapeutic Platform provides an effective treatment for clinically significant nightmares; avoids drug side-effects; and reduces the need for time intensive and often-unavailable psychological therapy sessions.”

The NightWare therapy is currently available on a limited basis through physician recommendation, but will hopefully launch in the early months of 2021. It will require a prescription and is intended for use among adults aged 22 years or older. It is not recommended for patients who sleepwalk or have violent episodes during nightmares. It is also not recommended as a standalone treatment for PTSD.

1. NightWare. We won’t rest until those with PTSD can. Accessed November 13, 2020. 

2. Muoio D. FDA grants De Novo clearance to prescription Apple Watch app for nightmare disorder. 

https://www.mobihealthnews.com/news/fda-grants-de-novo-clearance-prescription-apple-watch-app-nightmare-disorder

A new prescription smartwatch app may improve sleep quality for those with nightmare disorders. 

A New Way to “Watch” Your Nightmares

Evidence-Based Treatments for PTSD

What treatments are there to assist in the rehabilitation of veterans?

, about his work in the area of PTSD, trauma, and disaster. In this podcast he discusses:

2. What the military is (and is not) doing to help veterans with PTSD

3. His own experiences as a marine in Vietnam

Dr Figley is the Paul Henry Kurzweg, MD Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

How can psychiatrists meet the challenge of treating PTSD in veterans?

When the War Comes Home

According to Dr Currier, the 3 horsemen to be aware of are depression, excessive use of alcohol, and posttraumatic stress disorder (PTSD). If you are struggling with any of these, please seek mental health care; you cannot care for your patients to the full extent if you are not feeling your best. 

is a professor of psychiatry and chairman of the department of psychiatry & behavioral neurosciences at the University of South Florida.

What are the 3 signs, or horsemen, of physicians struggling? 

The 3 Horsemen of the Apocalypse

According to a recent study by researchers at the Uniformed Services University of the Health Sciences (USU)

, a motor neuron disease medication might also have the potential to help treat posttraumatic stress disorder (PTSD). As current pharmacologic treatments for PTSD have demonstrated limited efficacy, the study investigated the efficacy of glutamate modulation with riluzole augmentation for combat-related PTSD symptoms resistant to treatment.

Riluzole, commonly used to treat illnesses like Lou Gehrig disease, was tested to gauge whether it could be added to antidepressant medications that combat veterans were already taking for PTSD to help decrease their symptoms, particularly symptoms linked to suicide.

Army Colonel David Benedek, MD, chair of USU’s department of psychiatry and one of the study authors, said to the press, “At USU, we were particularly interested in the potential benefits of this medication for persons suffering from combat-related PTSD as persistent symptoms may negatively impact military readiness.”

A group of combat veterans receiving riluzole were compared to a group receiving a placebo, and while there was not a significant difference in overall symptoms, the group receiving riluzole did see significant improvement in a particular cluster of symptoms.

“Our results, though they should be interpreted cautiously, indicate that riluzole may reduce hyperarousal symptoms in combat veterans who are continuing to experience these symptoms despite treatment with antidepressants,” said Patricia Spangler, PhD, the study’s first author and a clinical research psychologist employed by the Henry M. Jackson Foundation in USU’s Center for the Study of Traumatic Stress (CSTS).

Hyperarousal is one of the primary symptoms of PTSD. When an individual’s body responds with high alert after thinking about their trauma, they respond as if a real threat is present. 

According to Spangler, it is important to focus on treating hyperarousal symptoms, as they are related to suicide attempts among combat veterans. She added that patients with high hyperarousal are less responsive to some PTSD psychotherapies.

1. Spangler PT, West JC, Dempsey CL, Possemato K, et al. Randomized controlled trial of riluzole augmentation for posttraumatic stress disorder: efficacy of a glutamatergic modulator for antidepressant-resistant symptoms. 

2. Uniformed Services University of the Health Sciences. Motor Neuron Drug Shows Promise as Treatment for PTSD Symptoms Linked to Suicide Attempts. 

A recent study found riluzole may effectively combat hyperarousal symptoms in combat veterans with PTSD. 

Motor Neuron Medication May Assist in Treatment of PTSD 

Scientific research has—and is—exploring psychedelic substances as medical treatment. Shannon Carlin, MA, AMFT, discussed the role of psychedelic substances in treating mental conditions and what clinicals trials are currently underway in her presentation at the Annual Psychiatric Times® World CME Conference™.

The Multidisciplinary Association for Psychedelic Studies (MAPS), founded in 2014, is a nonprofit that sponsors MDMA-assisted psychotherapy clinical trials. Carlin, an employee of the MAPS Public Benefit Corporation (MAPS PBC), explained how psychedelic drug development could benefit patients with posttraumatic stress disorder.

Carlin shared the effects MDMA had on mice: it promoted fear extinction, potentially allowed for some memory reconsolidation, and made the mice’s brains respond more like their adolescent brains, with greater rewards for socialization.

In human brains, she explained that MDMA reduced cerebral blood to the amygdala and hippocampus, decreased resting state connectivity between the medial prefrontal cortex and hippocampus, decreased activity in the insular cortex, and increased cerebral blood flow in the ventromedial prefrontal cortex. What does this mean? A total of 3 MDMA therapy sessions, followed by talk therapy integration sessions, both 90 minutes each, may assist patients with PTSD in overcoming their fear response, or fight-or-flight instincts.

In MAPS’s current therapy sessions, 2 clinicians work as co-therapists at every session, as the co-therapy model is designed to ensure consistent and through psychological care, although Carlin stated she was curious as to what might happen in a one-on-one session with a therapist. Further research might explore the safety and efficacy of 1 clinician rather than 2.

Carlin suggested she was hopeful that novel treatments of psychedelic therapies could bring new cures for mood and anxiety disorders.

The Annual Psychiatric Times® World CME Conference™ is being held October 15 – 17. More information can be found 

. Next year’s conference is scheduled for September 30 - October 2, 2021 in San Diego. 

New research is being conducted on how psychedelic substances may change the future of mental health care. Dr Carlin explained more in her speech at the Annual Psychiatric Times® World CME Conference™.

The New Frontier: Psychedelics as Treatment 

In a recent study, Pål Kristensen, PhD at the Centre for Crisis Psychology at the University of Bergen in Norway and colleagues examined the parents and siblings of the victims of the 2011 terrorism attacks in Norway as they went through the grieving process.

 They found nearly 80% of the study participants had a high level of grief and experienced a slow recovery, if any recovery at all.

“The terror attack in 2011 was a huge national tragedy that affected all of us deeply. Still,

we needed to learn about the long-term mental health effects and how we could help those who were affected the most—the bereaved,” Kristensen said to the press.

In the aforementioned attack, a far-right Norwegian-born terrorist used a car bomb explosion to kill 8 people in Oslo, then shot and killed 69 people on Utøya Island. Researchers reached out to the family members of these victims; of the 208 contacted, nearly 60% responded.

According to the study, families of terrorist victims are at high risk of developing Prolonged Grief Disorder (PGD). PGD is an ailment marked by an intense longing for the deceased, so consistent and severe that it negatively affects daily life.

Kristensen and colleagues examined participants at 18 months, 28 months, and 40 months after the attacks to gauge their grief levels. From these observations, they determined there were 3 potential trajectories: moderate grief that stabilized after 28 months; intense grief that slowly decreased after 28 to 40 months; extreme grief that persisted, becoming chronic. Of the participants, 13% felt no recovery, and 64% felt a slow recovery.

Other studies that examined grief typically found a track of resilience, where the participants could eventually recover post-tragedy. Kristensen et al. found no such trajectory among his participants. 

Kristensen stated he would like to see more longitudinal, qualitative studies to discover how to best support the needs of the grieving.

“We need to reach out to the terror-bereaved to offer help both early after an attack, but particularly across time when the social support is reduced,” Kristensen said.

Want more clinical tips for managing PTSD and grief in your patients? Join us at the Annual

World CME Conference October 15-17 to hear ideas and the latest clinical updates from Mark B. Hamner, MD. Register online https://www.gotoper.com/conferences/psychtimes/meetings/psychtimes20conference#registration

1. Kristensen P, Dyregrov K, Gjestad R. Different Trajectories of Prolonged Grief in Bereaved family members after Terror. 

. September 14, 2020. Accessed October 7, 2020. 

https://www.frontiersin.org/articles/10.3389/fpsyt.2020.545368/full

2. Recovery from grief is a slow, difficult process for families of victims of terrorist attacks. Frontiers Press Office. News release. October 14, 2020.

Terrorism is a crime from which the families of the victims may never recover. A recent study examines the grieving process in depth. 

PTSD