A man, 50, begins to experience shortness of breath and aching chest pains. He goes to his doctor, who diagnoses him with coronary heart disease, the leading cause of death in the United States. A year later the man has a heart attack and dies. Yet he had none of the risk factors associated with heart disease. So how did he get it?
The Framingham Heart Study, a long-term cardiovascular study on the residents of Framington, Massachusetts which ran from 1948 to the early 2000s, found that almost 90 percent of those with coronary heart disease have one of five recognized risk factors—smoking, high cholesterol, high blood pressure, obesity, diabetes, and physical inactivity. This information equipped doctors to provide preventive healthcare for heart failure by steering patients away from these risky or unhealthy behaviors.
The man above is hypothetical, but he's representative of 10 percent of Americans who die of coronary heart disease yet have none of the risk factors. Some of these people may, however, have something else in common: childhood trauma.
Dr. Vincent Felitti spoke about childhood trauma to an audience of therapists at the EMDR International Association's annual conference this year. (EMDR is an unconventional but increasingly popular treatment for childhood trauma.) “Not everyone is interested in serving out a full life sentence,” he said, referring to a life altered by an indelible childhood experience.
Over the past 18 years, Felitti and his professional partner, Dr. Robert Anda, have been researching the effects of adverse childhood experience (ACE) on long-term physical health. A researcher with the Centers for Disease Control, Felitti is the co-principal investigator of the Adverse Childhood Experiences Study that points to correlations between a person's ACE and his or her life expectancy and proclivity for certain diseases.
“When we looked at the 10 percent of patients dying of coronary heart disease without the recognized risk factors, we found that their ACE score explained it,” Felitti told AlterNet.
But the correlation may not stop with heart disease. Felitti's research has found correlations between ACE and cancer, pulmonary fibrosis, and sundry autoimmune diseases, among other biomedical diseases.
The ACE Study
In the early 1990s, Felitti and Anda designed an extensive questionnaire regarding individuals' personal history that they sent to members of Kaiser Permanente’s Department of Preventive Medicine in San Diego. Felitti established the department in 1975. Researchers have conducted detailed medical evaluations of approximately 58,000 adults every year.
The questionnaire asked respondents about eight categories of “adverse childhood experience” that included substance abuse in the household, parental divorce, sexual molestation, physical abuse, emotional neglect, or having a family member in prison. In designing the study, Felitti wanted to answer two questions: “Are major issues of childhood traumatic life experience common in a general population and if so how does it play out over time?”
Between 1995 and 1997, Felitti and Anda collected around 17,421 completed questionnaires—a 71 percent response rate of the initial 26,000 they contacted.
The demographic of the sample was characterized as mostly middle- to upper-middle-class: 74% had attended college; 69% were Caucasian; and the average age was 57.
For each category of trauma a patient had experienced, the doctors assigned one point that went toward the patient's overall ACE score. Of the over 17,000 respondents, one-third had an ACE score of zero; more than 25 percent had been beaten and another quarter had grown up in a house where alcoholism or drug use was present; one-sixth of the sample had an ACE score of four or higher.
The team of researchers then compared the respondent's ACE scores to their medical history and outcomes.
The first correlation was the easy one, Felitti says. Individuals with higher ACE scores developed coping mechanisms to reduce chronic major stress that are recognized as deleterious to health, such as smoking, drinking and drug use.
Compared to someone with an ACE score of zero, those with ACE scores of 4 or higher were twice as likely to smoke, seven times as likely to be a self-identified alcoholic, and 46 times more likely to use intravenous drugs.
The second correlation is the “harder one”: high ACE scores were also correlated with certain diseases.
People with ACE scores of four or higher were twice as likely to be diagnosed with cancer, twice as likely to have heart disease, four times as likely to suffer from emphysema or chronic bronchitis, and twelve times as likely to have committed suicide than those with an ACE score of zero.
While it might not be surprising that an anxious person is more likely to smoke and thus more likely to develop cancer, a high ACE score was associated with certain lethal diseases even when a so-called risky behavior was not involved.
Patients with ACE scores of seven or higher who didn't smoke, drink to excess, or overeat were 36 times more likely to develop coronary heart disease than those with an ACE score of zero.
“We ultimately looked at survival characteristics of the different ACE score statistics. Someone with an ACE score 6 or higher had almost a 20-year shortening of life expectancy,” Felitti said.
“The study makes it clear that time does not heal some of the adverse experiences we found so common in the childhoods of a large population of middle-aged, middle-class Americans,” Felitti wrote in his 2002 article, “The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold Into Lead."
“One does not ‘just get over’ some things, not even 50 years later.”
How It Works
Relentless, unrelieved stress produces chronically high levels of cortisol, which results in inflammation of the lining of the smallest blood vessels—the arteries—and “once the lining becomes inflamed, it acts as a magnet for cholesterol.”
When the Framingham Study was originally published, it was not understood that inflamed arteries cause retention of cholesterol, a discovery made by neuroscientist Bruce McKewan.
This suggests that ACE may actually be responsible for more than 10 percent of heart disease: when doctors cite high cholesterol as the cause of heart disease they may actually be identifying the symptom of the preceding cause: chronic stress, Felitti's findings suggest, is frequently precipitated by a childhood trauma.
Felitti likens heart disease to a burning house, equating high cholesterol to the smoke seen from the street: while it may be the most visible consequence of the fire inside, it is not the cause.
So for those individuals who do have the recognized risk factors—e.g. smoking—their propensity to contract certain lethal diseases may still be correlated to their ACE score.
The same pattern was found in other diseases, including chronic obstructive pulmonary disease (COPD), pulmonary fibrosis and bronchitis.
In his talk last September to EMDRIA, Felitti used the example of Patty, whose parents divorced in her early childhood. After that, her grandfather began to rape her on a regular basis. Patty showed up one day as Felitti's patient, “fairly comfortable in her early 40s,” he said, “interestingly comfortable because she knows she's going to die soon.”
Despite having never been a smoker or exposed to exceptionally dense air pollution, Patty had developed primary pulmonary fibrosis—meaning her lungs had converted to scar tissue. In addition to retaining cholesterol, inflamed arteries will eventually shut down and transform into scar tissue.
Felitti describes another woman. She is “well dressed, articulate, holds a significant position at a university; in other words the exact kind of person one would assume to protect oneself—no one thought to ask her about distasteful childhood events.”
The woman told Felitti that as a child she “was sexually abused routinely; neglected; starved; beaten” but notes that doctors did not typically ask her about childhood trauma when assessing her medical condition, which includes three different types of cancer, migraines and pelvic pain.
She described being in a state of constant fear and turmoil that is “just under the surface... of a veneer that's fairly thin.” But the veneer is thick enough to prevent doctors and others from recognizing the cause of her health problems.
The ACE study found that 11 percent of respondents have an ACE score of 5 or higher, which suggests to Felitti that doctors may be seeing many patients with childhood trauma without realizing that their medical complaints could be linked to them.
Felitti's background is not in psychoanalysis, psychology or psychiatry, the fields that have traditionally been assigned to handle emotional trauma. He began his medical career as an internist and infectious disease physician before his work at Kaiser Permanente.
His interest in the integration of a patient's full history into their medical records was prompted by his work at an obesity program, when he “stumbled accidentally into childhood sexual abuse.”
“We started asking people and nearly every other person in the program had horrific childhood abuse stories.”
He believes that ACE is one of the most common public health problems and yet it is still completely unrecognized.
Visit a physician for an annual checkup and you will be asked about your exercise regime, eating habits and penchant for imbibing alcohol or using drugs. But rarely if ever do doctors inquire about a patient's experiences in their earlier life.
Felitti wants to change all of that, and he has the data to support his aim.
When his team of researchers added trauma-related questions to a questionnaire that was given to 125,000 patients over two and a half years, there was a 35 percent reduction in doctor office visits in the subsequent year, and an 11 percent reduction in ER visits.
“The human and economic consequences of routinely asking and listening appear to be profound. Asking and listening is a rather powerful intervention.”
The reduction of doctor visits amounted to a savings of $2.5 billion.
But Felitti is very clear that this line of questioning cannot take place verbally. “It's clear to me that if this is done on an interpersonal basis it's doomed for failure because what goes on in the exam room is too wrought with subjectivity. Either the doctor is not prepared to listen, the patient senses the doctor is bored, the patient doesn't trust the doctor. There are many factors.”
Despite the far-reaching and economic implications of acknowledging patients' childhood experiences into medical practice, “the resistance has been intense.”
Jane Stevens, the founding editor of the website AcesTooHigh.com, has been tracking the integration of the ACE study into public institutions.
“This is a big change—it's a sea change—in our thinking about how the science effects practically every profession and certainly all of our human interactions,” Stevens told AlterNet.
A former reporter for the New York Times, Stevens remembers strong resistance from her health editor to cover the study in the 1990s. But nevertheless, she sees signs of change.
"I think that all the different professions are at the same point here in terms of integrating the results: schools criminal justice system, the medical profession are about at that same stage of beginning to integrate this into their practices because they're just figuring out how to do it."
On her website, Stevens keeps a running list of programs in schools, courts and communities that reflect implementation of the study. She is also currently working on book that is expected to be published next year that looks at how schools, homeless shelters, pediatricians, communities, courts, states are implementing a “trauma informed” approach.
The initial San Diego study has spawned over 80 academic articles, but the number of physicians integrating the findings into their practice remains small. A 2011 New Yorkerarticle profiled one pediatrician, Nadine Burke Harris, who set up a clinic in San Francisco's high-crime and impoverished neighborhood Bayview-Hunter's Point. Burke Harris has now started expanding her work into the criminal justice sector.
Felitti understands that the integration of the ACE Study into medicine would signify an upheaval in how the field currently functions. To demonstrate this he recalls the remarks of a colleague who received the first half of his medical education in Mexico. Felitti had asked him what the biggest difference between the two country's systems was and the man answered: “In Mexico, I learned how to treat sick people, in the United States I learned how to treat disease.”
Find out your own ACE score on Jane Stevens' website.