Annals of Behavioral Medicine

, Volume 21, Issue 3, pp 227–234 | Cite as

Electrocardiogram abnormalities among men with stress-related psychiatric disorders: Implications for coronary heart disease and clinical research

  • Joseph A. Boscarino
  • Jeani Chang
Article

Abstract

Research suggests psychological distress could result in arterial endothelial injury and coronary heart diseae (CHD). Studies also show Posttraumatic Stress Disorder (PTSD) victims have higher circulating catecholamines and other sympathoadrenal-neuroendocrine bioactive agents implicated in arterial damage. Here we analyzed resting 12-lead electrocardiographic (ECG) results among a national sample of 4,462 nonhospitalized male veterans (mean age=38) about 20 years after military service by current posttraumatic stress (n=54), general anxiety (n=186), and depression (n=157) disorders. ECGs were interpreted by board-certified cardiologists and summarized using theMinnesota Code Manual of Electrocardiographic Findings. Psychiatric disorders were diagnosed based on theDiagnostic Interview Schedule, Version III. Controlling for age, place of service, illicit drug use, medication use, race, body mass index, alcohol use, cigarette smoking, and education, PTSD (odds ratio [OR]=2.23, 95% confidence interval [CI]=1.17–4.26,p<0.05), anxiety (OR=1.51, 95% CI=1.03−2.22,p<0.05), and depression (OR=1.71, 95% CI=1.13−2.58,p<0.01) were associated with having a positive ECG finding. Specific results indicate PTSD was associated with atrioventricular (AV) conduction defects (OR=2.81, 95% CI=1.03−7.66,p<0.05) and infarctions (OR=4.44, 95% CI=1.20−16.43,p<0.05), while depression was associated with arrhythmias (OR=1.98, 95% CI=1.22−3.23,p<0.01). The PTSD associations for AV conduction defects and infarctions held, even after controlling for current anxiety and depression. These findings suggest psychological distress may result in CHD, because we controlled for obvious biases and confounders, the men studied had current PTSD due to combat exposures 20 years ago, combat exposure was associated with anxiety and depression among these men, and the men were disease free at military induction. These findings suggest the need for clinical surveillance among combat veterans, better psychobiologic models of CHD pathogenesis, and additional research.

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References

  1. (1).
    Blascovich J, Katkin ES (eds):Cardiovascular Reactivity to Psychological Stress and Diseases. Washington, DC: American Psychological Association, 1993.Google Scholar
  2. (2).
    Goldstein DS:Stress, Catecholamines, and Cardiovascular Disease. New York: Oxford University Press, 1995.Google Scholar
  3. (3).
    Manuck SB, Marsland AL, Kaplan JR, Williams JK: The pathogenicity of behavior and its neuroendocrine mediation: An example from coronary artery disease.Psychosomatic Medicine. 1995,57: 275–283.PubMedGoogle Scholar
  4. (4).
    Muldoon MF, Herbert TB, Patterson SM, et al: Effects of acute psychological stress on serum lipid levels, hemoconcentration, and blood viscosity.Archives of Internal Medicine. 1995,155:615–620.PubMedCrossRefGoogle Scholar
  5. (5).
    McCann BS, Magee MS, Broyles FC, et al: Acute psychological stress and epinephrine infusion in normolipidemic and hyperlipidemic men: Effects on plasma lipid and apoprotein concentrations.Psychosomatic Medicine. 1995,57:165–176.PubMedGoogle Scholar
  6. (6).
    Kaplan JR, Manuck SB, Williams JK, Strawn W: Psychological influences on atherosclerosis: Evidence for effects and mechanisms in nonhuman primates. In Blascovich J, Katkin ES (eds),Cardiovascular Reactivity to Psychological Stress and Disease, Washington, DC: American Psychological Association, 1993, 3–26.CrossRefGoogle Scholar
  7. (7).
    Boscarino JA: Diseases among men 20 years after exposure to severe stress: Implications for clinical research and medical care.Psychosomatic Medicine. 1997,59:605–614.PubMedGoogle Scholar
  8. (8).
    Chrousos GP, Gold PW: The concepts of stress and stress system disorders: Overview of physical and behavioral homeostasis.Journal of the American Medical Association. 1992,267:1244–1252.PubMedCrossRefGoogle Scholar
  9. (9).
    Boyce WT, Jemerin JM: Psychobiological differences in childhood stress response. I: Patterns of illness and susceptibility.Developmental and Behavioral Pediatrics. 1990,11:86–94.Google Scholar
  10. (10).
    Glaser R, Kiecolt-Glaser J (eds):Handbook of Stress and Immunity. New York: Academic Press, 1994.Google Scholar
  11. (11).
    Goldman HH:Review of General Psychiatry (4th Ed.). Norwalk, CT: Appleton and Lange, 1995.Google Scholar
  12. (12).
    van der Kolk BA, Saporta J: Biological response to psychic trauma. In Wilson JP, Raphael B (eds),International Handbook of Traumatic Stress Syndromes. New York: Plenum Press, 1993, 25–33.Google Scholar
  13. (13).
    van der Kolk B, Greenberg M, Boyd H, Krystal J: Inescapable shock, neurotransmitters, and addiction to trauma: Toward a psychobiology of posttraumatic stress.Biological Psychiatry. 1985,20:314–325.PubMedCrossRefGoogle Scholar
  14. (14).
    Greenspan FS, Baxter JD:Basic and Clinical Endocrinology (4th Ed.) Norwal, CT: Appleton and Lange, 1994.Google Scholar
  15. (15).
    Boscarino JA: Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: Findings and clinical implications.Journal of Consulting and Clinical Psychology. 1996,63:191–201.CrossRefGoogle Scholar
  16. (16).
    Mason JW, Giller EL, Kosten TR, Ostroff RB, Podd L: Urinary free cortisol levels in posttraumatic stress disorder patients.Journal of Nervous and Mental Disease. 1986,174:145–149.PubMedCrossRefGoogle Scholar
  17. (17).
    Yehuda R, Southwick SM, Nussbaum G, et al: Low urinary cortisol excretion in patients with posttraumatic stress disorder.Journal of Nervous and Mental Disease. 1990,178:366–369.PubMedCrossRefGoogle Scholar
  18. (18).
    Yehuda R, Southwick S, Giller EL, Ma X, Mason JW: Urinary catecholamine excretion and severity of PTSD symptoms in Vietnam combat veterans.Journal of Nervous and Mental Disease. 1992,180:321–325.PubMedCrossRefGoogle Scholar
  19. (19).
    Blanchard EB, Kolb L, Prins A: Psychophysiological responses in diagnosis of posttraumatic stress disorder in Vietnam veterans.Journal of Nervous and Mental Disease. 1991,179:97–101.PubMedCrossRefGoogle Scholar
  20. (20).
    Mason JM, Giller EL, Kosten TR, Harkness L: Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder.Journal of Nervous and Mental Disease. 1988.176:498–502.PubMedCrossRefGoogle Scholar
  21. (21).
    Eliot RS, Morales-Ballejo HM: The heart, emotional stress, and psychiatric disorders. In Schlant RC, Alexander RW, O’Rourke RA, Roberts R, Sonnenblick EH (eds),Hurst’s The Heart: Arteries and Veins (8th Ed.), New York: McGraw-Hill, 1994, 2087–2097.Google Scholar
  22. (22).
    Hayward C: Psychiatric illness and cardiovascular disease risk.Epidemiologic Reviews. 1995,17:129–138.PubMedGoogle Scholar
  23. (23).
    Glassman AH, Shapiro PA: Depression and the course of coronary artery disease.American Journal of Psychiatry. 1998,155:4–11.PubMedGoogle Scholar
  24. (24).
    Booth-Kewley S, Friedman HS: Psychological predictors of heart disease: A quantitative review.Psychological Bulletin. 1987,101:343–362.PubMedCrossRefGoogle Scholar
  25. (25).
    Kubzansky LD, Kawachi I, Spiro A, et al: Is worrying bad for your heart? A prospective study of worry and coronary heart disease in the Normative Aging Study.Circulation. 1997,95:818–824.PubMedGoogle Scholar
  26. (26).
    Kulka RA, Schlenger WE, Fairbank JA, et al:Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel, 1990.Google Scholar
  27. (27).
    Boscarino JA: Posttraumatic stress and associated disorders among Vietnam veterans: The significance of combat and social support.Journal of Traumatic Stress. 1995,8:317–336.PubMedGoogle Scholar
  28. (28).
    Houston BK: Psychological variables and cardiovascular and neuroendocrine reactivity. In Matthews KA, Weiss SM, Detre T, et al (eds),Handbook of Stress, Reactivity, and Cardiovascular Disease. New York: Wiley, 1986, 207–230.Google Scholar
  29. (29).
    Wright RA, Contrada RJ, Glass DC: Psychophysiologic correlates of Type A behavior. In Katkin ES, Manuck SB (eds),Advances in Behavioral Medicine (Vol. 1). Greenwich, CT: JAI Press, 1985, 39–88.Google Scholar
  30. (30).
    Blascovich J, Katkin ES: Psychological stress testing for coronary heart disease. In Blascovich J, Katkin ES (eds),Cardiovascular Reactivity to Psychological Stress and Disease. Washington, DC: American Psychological Association, 1993, 27–45.CrossRefGoogle Scholar
  31. (31).
    Dohrenwend BP: Sociocultural and social-psychological factors in the genesis of mental disorders.Journal of Health and Social Behavior. 1975,16:365–392.PubMedCrossRefGoogle Scholar
  32. (32).
    Yager T, Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation.Archives of General Psychiatry. 1984,41:327–333.PubMedGoogle Scholar
  33. (33).
    Centers for Disease Control: Health status of Vietnam veterans: I. Psychosocial characteristics.Journal of the American Medical Association. 1988,259:2701–2707.CrossRefGoogle Scholar
  34. (34).
    Wilson JP, Raphael B (eds):International Handbook of Traumatic Stress Syndromes. New York: Plenum Press, 1993.Google Scholar
  35. (35).
    Green BL, Lindy JD, Grace MC, Leonard AC: Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample.Journal of Nervous and Mental Disease. 1992,180: 760–766.PubMedCrossRefGoogle Scholar
  36. (36).
    Centers for Disease Control:Vietnam Experience Study: Health Status of Vietnam Veterans: Volume IV. Psychological and Neuropsychological Evaluation. Atlanta, GA: Centers for Disease Control, 1989.Google Scholar
  37. (37).
    American Psychiatric Association:Diagnostic and Statistical Manual of Mental Disorders (4th Ed.), Washington, DC: American Psychiatric Association, 1994.Google Scholar
  38. (38).
    Yehuda R, Giller EL, Levengood RA, Southwick SM, Siever LJ: Hypothalamic-pituitary-adrenal functioning in posttraumatic stress disorder: Expanding the concept of the stress response spectrum. In Friedman MJ, Charney DS, Deutch AY (eds),Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to PTSD. Philadelphia, PA: Lippincott-Raven Publishers, 1995, 351–365.Google Scholar
  39. (39).
    Yehuda R, Boisoneau D, Lowy MT, Giller EL: Dose-response changes in plasma cortisol and lymphocyte glucocorticoid receptors following dexamethasone administration in combat veterans with and without posttraumatic stress disorder.Archives of General Psychiatry. 1995,52:583–593.PubMedGoogle Scholar
  40. (40).
    Yehuda R, McFarlane AC: Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis.American Journal of Psychiatry. 1995,152:1705–1713.PubMedGoogle Scholar
  41. (41).
    Centers for Disease Control:Vietnam Experience Study: Health Status of Vietnam Veterans: Volume III. Medical Examinations. Atlanta, GA: Centers for Disease Control, 1989.Google Scholar
  42. (42).
    Centers for Disease Control:Vietnam Experience Study: Health Status of Vietnam Veterans: Volume II. Telephone Interview. Atlanta, GA: Centers for Disease Control, 1989.Google Scholar
  43. (43).
    Centers for Disease Control:Vietnam Experience Study: Health Status of Vietnam Veterans: Supplement C. Medical and Psychological Procedure Manuals and Forms. Atlanta, GA: Centers for Disease Control, 1989.Google Scholar
  44. (44).
    Prineas RJ, Crow RS, Blackburn H:The Minnesota Code Manual of Electrocardiographic Findings: Standards and Procedures for Measurement and Classification. Boston, MA: John Wright/PSG Inc., 1982.Google Scholar
  45. (45).
    Tunstall-Pedoe H, Kuulasmaa K, Amoyel P, et al: Myocardial infarction and coronary deaths in the World Health Organization MONICA Project: Registration procedures, event rates, and casefatality rates in 38 populations from 21 countries in four continents.Circulation. 1994,90:583–612.PubMedGoogle Scholar
  46. (46).
    Robins LN, Helzer JE, Cottler LB:The Diagnostic Interview Schedules Training Manual, Version III-A. St. Louis, MO: Veterans Administration, 1987.Google Scholar
  47. (47).
    American Psychiatric Association:Diagnostic and Statistical Manual of Mental Disorders (3rd Ed.). Washington, DC: American Psychiatric Association, 1980.Google Scholar
  48. (48).
    Robins LN, Helzer JE, Croughan J, Ratcliff KS: National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity.Archives of General Psychiatry. 1981,38: 381–389.PubMedGoogle Scholar
  49. (49).
    Robins LN, Helzer JE, Ratcliff KS, Seyfried W: Validity of the Diagnostic Interview Schedule, Version II: DSM-III Diagnoses.Psychological Medicine. 1982,12:855–870.PubMedGoogle Scholar
  50. (50).
    Baskir LM, Strauss WA:Chance and Circumstance: The Draft, the War and the Vietnam Generation. New York: Vintage Books, 1978.Google Scholar
  51. (51).
    Syme LS: Social determinants of disease. In Last JM, Wallace RB, and Associates (eds),Maxcy-Rosenau-Last: Public Health and Preventive Medicine (13th Ed.). Norwalk, CT: Appleton and Lange, 1992, 687–700.Google Scholar
  52. (52).
    Adler NE, Boyce T, Chesney MA, et al: Socioeconomic status and health: The challenge of the gradient.American Psychologist. 1994,49:15–24.PubMedCrossRefGoogle Scholar
  53. (53).
    SPSS:SPSS ® for Windows (Version 7.5). Chicago, IL: SPSS, Inc., 1997.Google Scholar
  54. (54).
    Stata Corporation:Stata ® (Release 5). College Station, TX: Stata Corporation, 1997.Google Scholar
  55. (55).
    Hosmer DW, Lemeshow S:Applied Logistic Regression. New York: Wiley, 1989.Google Scholar
  56. (56).
    SAS Institute:SAS ® for Windows (Version 6). Cary, NC: SAS Institute, Inc., 1993.Google Scholar
  57. (57).
    Hayward C: Psychiatric illness and cardiovascular disease risk.Epidemiologic Review. 1995,17:129–138.Google Scholar
  58. (58).
    Kandel ER, Schwartz JH, Jessell TM (eds):Principles of Neural Science (3rd Ed.). Norwalk, CT: Appleton and Lange, 1991.Google Scholar
  59. (59).
    Keane TM, Zimering RT, Caddell JM: A behavioral formulation of posttraumatic stress disorders in Vietnam veterans.Behavior Therapist. 1985,8:9–12.Google Scholar
  60. (60).
    McAllister WR, McAllister DE: Two-factor fear theory: Implications for understanding anxiety-based clinical phenomena. In O’Donohue W, Krasner L (eds),Theories of Behavior Therapy: Exploring Behavior Change. Washington, DC: American Psychological Association, 1995.Google Scholar
  61. (61).
    Boscarino JA, Chang C: Higher abnormal leukocyte and lymphocyte counts 20 years after exposure to severe stress: Research and clinical implications.Psychosomatic Medicine. 1999,61:378–386.PubMedGoogle Scholar
  62. (62).
    Luscinskas FW, Gimbrone MA: Endothelial-dependent mechanisms in chronic inflammatory leukocyte recruitment. InAnnual Review of Medicine: Volume 47, 1996. Palo Alto, CA: Annual Reviews, Inc., 1996, 413–421.Google Scholar
  63. (63).
    McCarren M, Janes GR, Goldberg J, et al: A twin study of the association of posttraumatic stress and combat exposure with long-term socioeconomic status in Vietnam veterans.Journal of Traumatic Stress. 1995,8:111–124.PubMedCrossRefGoogle Scholar
  64. (64).
    Maier SF, Watkins LR, Fleshner M: Psychoneuroimmunology: The interface between behavior, brain, and immunity.American Psychologist. 1994,49:1004–1017.PubMedCrossRefGoogle Scholar
  65. (65).
    Schlant RC, Alexander RW, O’Rourke RA, Roberts R, Sonnenblick EH (eds):Hurst’s The Heart: Arteries and Veins (8th Ed.). New York: McGraw-Hill, 1994.Google Scholar
  66. (66).
    Booth-Kewley S, Friedman HS: Psychological predictors of heart disease: A quantitative review.Psychological Bulletin. 1987,101: 343–362.PubMedCrossRefGoogle Scholar
  67. (67).
    Flectcher GF, Schlant RC: The exercise test. In Schlant RC, Alexander RW, O’Rourke RA, Roberts R, Sonnenblick EH (eds),Hurst’s The Heart: Arteries and Veins (8th Ed.). New York: McGraw-Hill, 1994, 423–440.Google Scholar
  68. (68).
    Braunwald E: Shattuck Lecture—Cardiovascular medicine at the turn of the millennium: Triumphs, concerns, and opportunities.New England Journal of Medicine. 1997,337:1360–1369.PubMedCrossRefGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 1999

Authors and Affiliations

  • Joseph A. Boscarino
    • 1
  • Jeani Chang
  1. 1.Center for Outcomes Measurement and Performance AssessmentMerck-Medco Managed CareFranklin Lakes

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