I have long been interested in the association between mental disorders and various physical health problems.
I've written extensively in the past on the issue of obesity and its correlation with people that suffer from PTSD. I've also seen research associating PTSD with lower rates of smoking cessation which in turn can result in other health problems such as cardiovascular disease and lung cancer.
But today I want to focus on the link between PTSD and auto immune disorders.
The VA highlighted a study that was comprised of more than 666,000 veterans of Iraq and Afghanistan who also had PTSD and auto immune disorders. These auto immune disorders included:
- Rheumatoid arthritis
- Multiple sclerosis
- Inflammation of the thyroid
- Inflammatory bowel disease
The study's authors found that there was a two-fold increase in the risk among those with PTSD compared to those who had no psychiatric diagnoses.
In other words, a two-fold increase in the risk that you'll get an auto immune disease, such as lupus or multiple sclerosis or irritable bowel disease or thyroid inflammation, or rheumatoid arthritis, if you have PTSD.
Although evidence may suggest an increased risk of developing these diseases in patients who have other psychiatric diagnoses besides PTSD, the study's researchers found that PTSD still outperformed other psychiatric diagnoses in terms of increasing one's risk for getting auto immune disease. For instance, veterans with PTSD compared to those with other psychiatric diagnoses still had a 51 percent greater risk of developing the auto immune disease.
The reasons for this linkage are not fully known. Suggestions have been made that include hormonal changes brought on by PTSD or a decline in health habits that are common in those with PTSD.
These things include such factors as smoking, drinking, poor diet, or impaired sleep. I've written previously in other articles about the association between PTSD and the decline in one's health and general health habits. This includes inactivity and poor diet. Other studies have clearly shown a higher rate of physical inactivity among those suffering from PTSD versus those who don't have PTSD.
Perhaps a similar issue could be going on here to explain these higher correlations of veterans with PTSD who also have auto immune disease.
Finally, a third possible explanation is that perhaps there is a pre-existing genetic or environmental risk factor that might lay the ground work for both conditions.
In other words, perhaps there is a genetic predisposition that makes one more likely to develop PTSD and in turn also more likely to develop auto immune disease. We know that not everybody exposed to a stressful event develops PTSD.
There's a certain resiliency that some people have based upon their background, upbringing, and perhaps even religious beliefs.
So these are the possible theories that explain a link between PTSD and auto immune disease. It is important to observe that the research does not show that PTSD causes auto immune disease. The study merely shows that there is a relationship.
Similar studies have also shown a relationship to other diseases of a physical nature, such as heart disease. This explains why other researchers continue to observe the existence of a growing body of literature that highlights the increased risk for other chronic physical diseases in those veterans that suffer from PTSD and other psychiatric disorders.
As a veteran's disability benefits attorney who has been representing veterans for many years, I can say that anecdotally it has been my experience that people with PTSD or other psychiatric diagnoses tend to have higher rates of other physical health problems.
As the study's authors have noted, although there is no explanation to support a causative connection between PTSD and these auto immune problems, there is a relationship.
I personally believe that that relationship can be explained through lifestyle factors that tend to be the linkage between the PTSD and the other health problems. For instance, veterans with severe PTSD may tend to turn to comfort foods as a way of coping and self-medicating, and these foods in turn may be less healthy and more fattening, which in turn can lead to obesity, which in turn can lead to type 2 diabetes and cardiovascular disease.
Perhaps the poor physical activity and diet play contributory roles in the development of auto immune disease. But in trying to prove a claim for service connection for an auto immune disease secondary to PTSD, you're going to have to rely heavily on the concept of an association. VA could come back and argue that there's no causative link but merely an association.
In response I would argue that the standard of proof to prove service connection for an auto immune disease secondary to PTSD is very low. One merely needs to prove that it's as likely as not caused by the PTSD. This means that it must only reach the level of 50 percent probability. I would submit that a strong association and correlation is enough to reach the 50 percent probability threshold in terms of establishing proof of a causative link.
Of interesting note is a book that was written a number of years ago by a professor from Cornell University named T. Colin Campbell. His book known as The China Study provided an in-depth discussion as to the linkage between dietary habits and numerous diseases, such as auto immune diseases. He discusses things like type 1 diabetes as an auto immune disease and multiple sclerosis.
His central thesis is that some of these disorders occur in large numbers among populations that eat certain diets that are considered less optimal. So perhaps the mediating factor between the PTSD and these auto immune diseases could perhaps be dietary and the poor dietary practices are the result of mental impairment due to PTSD.
Now when I say mental impairment I do not mean that a person's losing their ability to determine what they're doing. Rather, I'm referring to the lack of motivation that comes with severe, debilitating psychiatric disorders.
Also known as a disease symptom for PTSD is impaired judgement.
For a veteran suffering from PTSD, his only concern may be the immediate desire to quiet the anxiety in his head. This may mean making decisions for short term amelioration of temporary symptoms but with the long-term consequence of further declines in heath.
For instance, one may make the decision to continue to smoke at high levels because they find that this habit relaxes them. But in the long run, this will lead to more health problems, which in turn can lead to further depression. The other factor that may impact dietary practices amongst those with PTSD is that in severe cases of PTSD one's earning potential is impaired and often the disorder is so disabling that a veteran is unable to work as a result of their PTSD. With limited finances, access to high quality food may be limited.
This may also explain some declines in the health of veterans suffering from PTSD who are unable to work. It could also mean that lack of money could impair one's ability to exercise in the sense that some gym memberships cost money and home exercise equipment may also be costly and unavailable to those who are unable to earn an income.
With respect to the food issue, I note that perhaps our government should consider subsidizing healthy food and imposing surcharges on food that is known to cause deleterious health impacts. This would have the effect of helping our veterans be able to afford that which is healthy for them so they can lower their risk for developing some of the problems that apparently are now known to be associated with PTSD.
So How Do You Prove Service Connection For Auto Immune Disease Secondary to PTSD?
As I noted above, researchers acknowledge that there's no causative link between PTSD and auto immune disease. In other words, PTSD does not specifically cause auto immune diseases.
However, this does not mean you cannot make a claim for service connection for auto immune disease secondary to PTSD.
Simply stated, you must marshal significant evidence to make the association so clear and so contrasted with people that don't have PTSD that the VA is forced to conclude that there's got to be a relationship and therefore service connection.
As a veteran's disability attorney, I have won many cases based on mere associations rather than actual causation.
The problem is that in the scientific world scientific causation is at a very high level of proof. The level of proof we need to prove service connection for PTSD or for a secondary condition due to PTSD is much lower. We're talking about a correlation of at least 50 percent probability. So if you can prove that there's an association to a degree of 50 percent probability, then you win.
Therefore, when you see striking correlations and associations such as a two-fold increase in risk, then you can argue that the association is high enough to reach the 50 percent probability threshold. So although PTSD may not be something that directly causes auto immune conditions, PTSD does lead to certain lifestyle and health impairments that in turn can cause a myriad of health problems, such as auto immune disease and heart disease.
I've already discussed the obesity link in other articles and this may be the factor that explains these associations.
So How Do You Prove A High Level Of Association?
Obviously lots of medical literature and articles from respected, peer reviewed journals would certainly help. But VA is unlikely to grant a claim simply based upon journal articles that you obtain and submit on your own.
It's better to have a medical expert say there's an association and then have the medical expert cite to the medical articles. You can still include the medical articles in your submission to the VA but don't just submit medical articles by themselves. VA typically downgrades the weight that they will give to medical articles, saying things like they're too generic and things like that.
So to make a medical article less generic, it is best to have the medical expert draw a correlation and cite to the article. That way your medical expert's opinion will have the weight of being backed up by the peer reviewed scientific literature.
But How Do You Find Such A Medical Expert?
Realistically, asking your VA treating physician to provide such an article is not going to work. You're unlikely to get a medical opinion from them. In addition, your typical treating primary care physician in the private sector is unlikely to give you a report that has any value.
In my experience their reports tend to be very short, without an adequate rationale, and without consideration of the entire claims file. If they don't provide a rationale and they don't review the claims file, VA will reject their opinion as being inadequate.
In addition, private treating doctors typically hedge too much in their opinions and do not use the right language. In short, their opinions tend to be speculative. Therefore, you really need to hire a professional expert witness who has experience in VA cases. These experts can be hard to find for the average veteran who's involved in a claim.
One of the advantages of having a veteran's benefits attorney is that they can typically help a veteran acquire the evidence they need in terms of expert reports. Lawyers who practice in this area typically have a stable of trusted experts who have worked on cases in the past with great success.
If you have PTSD and you have developed auto immune disease that now makes it impossible for you to work, then you need to strongly consider filing a claim for secondary service connection. If you already have a claim pending and it's been denied, then you need to retain a qualified veteran's disability attorney who can assist you with the appeal and who knows this area of law and the medical literature.
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