Researchers have demonstrated and successfully replicated strong, negative relationships between childhood maltreatment and adverse health consequences in women. Likewise, relationships between PTSD and poor health-related quality of life in female veterans have been amply documented. These studies, in concert, leave little doubt that childhood maltreatment and PTSD are associated with substantial functional adversity in women. Given these observations, an obvious question is to what extent PTSD mediates the relationship between childhood maltreatment and poor health functioning.
We found that the strongest path to physical and mental health functioning was a direct (negative) path from PTSD, indicating that more PTSD symptoms are associated with poorer health functioning. This path represented a large effect size with an additional, small effect size for the direct path from childhood nonsexual trauma to health functioning. PTSD symptoms were associated with childhood maltreatment and adult sexual assault by approximately equal moderate effect sizes. A number of researchers have shown that PTSD at least partially mediates the effects of trauma exposure (eg, combat) in adulthood on health outcomes. In the context of these earlier observations, our finding that PTSD largely mediated the effects of childhood maltreatment and fully mediated the effect of adult sexual assault on health functioning completes the picture of PTSD as a critical mediator of health outcomes to a wide spectrum of traumatic antecedents, both in childhood and adulthood. From a public health perspective, given its placement in the pathway from trauma to adverse health outcomes, a focus on aggressively identifying and treating PTSD may have substantial salutary effects on women’s health functioning and use of health services.23,64
Researchers should test this hypothesis in randomized clinical trials in which they target women with PTSD in general medical settings. Given the high rates of trauma and PTSD among female veterans22,35,39
the VA system may be an ideal system of care in which to conduct such a study.
Our study has a number of limitations that must be considered when interpreting our results. First, this is a cross-sectional study, and although the SEM approach compares alternative models to enable inferences about causal pathways, definitive statements about causality can be made only with prospective, longitudinal data. Second, the model tested was not inclusive of all potentially relevant kinds of trauma (eg, domestic violence)65
because our focus was on childhood maltreatment and sexual trauma; more inclusive models may lead to different results. Third, PTSD symptoms were not explicitly linked to a particular “worst” trauma, as is customarily done in epidemiologic surveys, and we did not include PTSD in the model as a diagnosis but, rather, as a continuous measure of posttraumatic stress-related symptoms. There is, however, considerable justification for this approach. Taxometric analyses of PTSD symptoms have yielded a dimensional solution, suggesting that PTSD reflects the upper end of a stress-response continuum rather than a discrete clinical syndrome.66
Fourth, we did not include other potentially relevant symptom domains that may be part of the pathway from PTSD to poor health outcomes (eg, depression, substance abuse),67-70
which may have yielded different results had they been included. Fifth, current health state may bias retrospective reporting of trauma,71
although there is considerable evidence to suggest that individuals are highly reliable in their recollection of traumatic experiences.72
Sixth, although our response rate (56%) is respectable by survey standards—and similar to response rates were obtained in similar VA outpatient settings (eg, 65% in a recent survey35
)—a higher response rate would have provided greater reassurance about the generalizability of our findings. Last, self-reported physical and mental health functioning, as characterized by the SF-36, may provide different results than do more specific disease-related outcomes (eg, major depression, heart disease).8,73
Cloitre et al74
found that exposure to trauma, but not PTSD, was related to the number of medical problems endorsed, whereas PTSD, but not trauma exposure, was associated with perceived health. However, the SF-36 is a robust, widely used summary measure of health-related functioning that transcends specific diagnoses.
I n conclusion, much of the variance in poor health outcomes associated with childhood maltreatment and adult sexual assault in women may be conveyed through PTSD. Investigators must replicate these observations in prospective, longitudinal studies before definitive conclusions about causality can be made. Nonetheless, even at this juncture, these findings should strengthen efforts directed at identifying and treating PTSD in female victims of childhood maltreatment with the aim of preventing or attenuating poor health outcomes and high healthcare costs.64,75
It is possible, for example, that better educating physicians about PTSD and its effects may lead to improved care and improved outcomes. Our findings also point to the need for future researchers to determine the mechanisms by which PTSD mediates the health impact of trauma and develop methods to enhance resilience to these injurious effects.