Comorbidity in illness-induced posttraumatic stress disorder versus posttraumatic stress disorder due to external events in a nationally representative study

Accepted Manuscript Comorbidity in illness-induced posttraumatic stress disorder versus posttraumatic stress disorder due to external events in a nationally representative study

Jordana L. Sommer, Natalie Mota, Donald Edmondson, Renée ElGabalawy PII: DOI: Reference:

S0163-8343(17)30415-2 doi:10.1016/j.genhosppsych.2018.02.004 GHP 7287

To appear in:

General Hospital Psychiatry

Received date: Revised date: Accepted date:

14 September 2017 3 February 2018 7 February 2018

Please cite this article as: Jordana L. Sommer, Natalie Mota, Donald Edmondson, Renée El-Gabalawy , Comorbidity in illness-induced posttraumatic stress disorder versus posttraumatic stress disorder due to external events in a nationally representative study. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ghp(2017), doi:10.1016/j.genhosppsych.2018.02.004

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Comorbidity in Illness-Induced Posttraumatic Stress Disorder versus Posttraumatic Stress

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Disorder due to External Events in a Nationally Representative Study

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Jordana L. Sommer BA(Hons.)1,2, Natalie Mota MA PhD3,4, Donald Edmondson PhD, MPH5,

Department of Anesthesia & Perioperative Medicine, Max Rady College of Medicine,

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Department of Psychology, Faculty of Arts, University of Manitoba

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& Renée El-Gabalawy MA PhD1,2,3,4

University of Manitoba Department of Clinical Health Psychology, Max Rady College of Medicine,

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Department of Psychiatry, Max Rady College of Medicine, University of Manitoba 5

Center for Behavioral Cardiovascular Health, Department of Medicine,

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University of Manitoba

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Columbia University Medical Center

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Conflicts of Interest: None. Corresponding Author:

Renée El-Gabalawy, MA, Ph.D. AE209, Harry Medovy House, 671 William Avenue Winnipeg, Manitoba, CANADA, R3E 0Z2 E-mail: [email protected] Phone: (204)-787-2212; Fax: (204)-787-4291

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Abstract Objective: The current study compared physical and mental health characteristics and quality of life of illness-induced posttraumatic stress disorder (PTSD) versus those with PTSD due to external traumatic events in a population-based sample.

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Method: PTSD was assessed with the Alcohol Use Disorder and Associated Disabilities

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Interview Schedule (AUDADIS-5) using DSM-5 criteria in the 2012-2013 National

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Epidemiologic Survey on Alcohol and Related Conditions. Participants with past-year PTSD (n = 1,779) were categorized into two groups: illness-induced (6.5%) and other trauma-induced

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PTSD (92.9%) based on index trauma. Group differences in physical health, mental health, and

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quality of life were estimated using multiple logistic and linear regressions with adjustment for demographics and medical morbidity.

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Results: Compared to PTSD due to external events, illness-induced PTSD had higher rates of

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life-threatening illness in the past year. Illness-induced PTSD compared to PTSD due to external events was associated with reduced odds of depressive/bipolar disorders and antisocial

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personality disorder, but increased odds of cannabis use disorder. The groups did not differ on

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quality of life after accounting for medical morbidity. Conclusion: Illness-induced PTSD is common among American adults and has a similar impact

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on quality of life as PTSD due to external events, but may have distinct mental health correlates. keywords: illness, trauma, posttraumatic stress, health-related correlates

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1. Introduction There has been recent interest in examining posttraumatic stress disorder (PTSD) as a result of physical illness (i.e., illness-induced PTSD), including cancer (e.g., 1, 2), cardiovascular disease (e.g., 3, 4), stroke (e.g., 5, 6), and critical illness more generally (e.g., 7, 8). Currently,

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the majority of research in this area has focused on life-threatening illnesses in particular. Across

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studies, the total estimated prevalence of illness-induced PTSD (among individuals who

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experience acute life-threatening medical events) ranges from 12-25% (5, 9, 10). Some investigators have suggested that the presentation of illness-induced PTSD may

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differ from that of PTSD due to external events such as sexual assault or military-related trauma

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(i.e., other trauma-induced PTSD; e.g., 4, 10, 11). Specifically, in illness-induced PTSD, survivors may perceive illness as an ongoing and internal event, rather than a distinct and

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external event (10). Further, research by our group has found that illness-induced PTSD is also

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associated with demographic distinctions from traditional conceptualizations of PTSD. Specifically, in comparison to other trauma-induced PTSD, illness-induced PTSD is associated

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with older age and a significantly higher proportion of males are affected than other trauma-

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induced PTSD (12). In addition, the symptom presentation of illness-induced PTSD may differ from other trauma-induced PTSD; intrusive thoughts are future-oriented rather than past-

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oriented, avoidance can be particularly difficult, and hyperarousal symptoms may be associated with somatic symptoms (e.g., heart palpitations). However, in both illness-induced and other trauma-induced cases, PTSD symptoms are maintained by a fear of mortality (10). In preliminary support of these differentiating symptom presentations, our group has found that illness-induced PTSD is associated with fewer symptoms of re-experiencing, alterations in cognition and mood, and hyperarousal compared to other trauma-induced PTSD (12). We

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suggest that this finding may not necessarily result from less severe symptomatology, but rather because current DSM nomenclature and diagnostic criteria may not accurately capture the experience of illness-induced PTSD and thus may yield underestimates of true symptom burden. The unique demographic characteristics and symptom profile of illness-induced PTSD further

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support its distinctiveness from traditional conceptualizations of PTSD.

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The illness-induced PTSD literature is in its infancy, and the majority of studies that have

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examined the incidence, correlates, and risk factors of illness-induced PTSD have focused on samples of patients with a specific illness (e.g., cancer-related PTSD, cardiac disease induced-

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PTSD), thus limiting their generalizability. For example, studies have identified depression,

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anxiety, and poor quality of life as correlates of illness-induced PTSD in patients following myocardial infarction, cardiac surgery, and cancer diagnosis (all individually; e.g., 13, 14, 15).

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Further, most of the literature on illness-induced PTSD has used the Diagnostic and Statistical

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Manual of Mental Disorders-fourth edition (DSM-IV; 16) criteria, as opposed to DSM-5 (17) criteria. Significant changes have been made to the PTSD diagnostic criteria in the DSM-5 (e.g.,

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now classified as a trauma and stressor-related disorder, addition of a fourth symptom cluster).

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Most notably, according to the DSM-5: “A life threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as

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traumatic events involve sudden, catastrophic events” (17, p. 274). This addition to diagnostic nomenclature may impact the likelihood of a diagnosis of illness-induced PTSD, thus affecting both research on the topic and clinical diagnoses, which ultimately may impact access to appropriate treatments. Prior studies on illness-induced PTSD have also largely relied on selfreport measures to assess PTSD symptomatology (1, 7, 11), which have been associated with substantially higher prevalence estimates of illness-induced PTSD, compared to those attained

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using gold-standard diagnostic interviews (4, 9, 11, 18). Finally, to the best of our knowledge, no studies to date have used a population-based sample to compare illness-induced PTSD to other trauma-induced PTSD on comorbidities, further limiting generalizability. This has resulted in an absence of information regarding comorbidities unique to this clinical presentation.

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In light of the above-described gaps in the current literature, this study aims to compare

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mental and physical health-related correlates (i.e., life-threatening conditions, mental health

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conditions, health-related quality of life) of illness-induced PTSD versus other trauma-induced PTSD in a nationally representative sample of United States (U.S.) adults. This study used a

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well-validated, semi-structured clinical interview to assess PTSD by DSM-5 diagnostic criteria.

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2. Methods 2.1 Sample

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We analyzed data collected as part of 2012-2013 National Epidemiologic Survey on

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Alcohol and Related Conditions (NESARC-III), sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA; 19). As detailed by Grant and colleagues (19), the NESARC-III

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(N = 36,309; response rate = 60.1%) was conducted between April 2012 and June 2013 and was

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administered to a nationally representative sample of U.S. civilians, ages 18 years or older. The sample excluded disabled and institutionalized individuals. Participants were randomly selected

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using multistage probability sampling. Trained interviewers conducted face-to-face interviews with participants. Data were weighted according to the 2012 American Community Survey (20) to adjust for nonresponse and oversampling and to ensure representation of the U.S. population. All participants consented to participate and the Westat Institutional Review Board and the Combined Neuroscience Institutional Review Board of the National Institutes of Health provided ethical review and approval. Further, institutional ethics board approval was obtained for use of

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these data at the [edited out for blind review], and the study was approved by the NESARC-III Data Access Committee. 2.2 Measures 2.2.1 Posttraumatic stress disorder. The Alcohol Use Disorder and Associated

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Disabilities Interview Schedule (AUDADIS-5; 21) assessed past-year PTSD. The AUDADIS-5

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is a semi-structured diagnostic interview designed for use by experienced lay interviewers. The

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AUDADIS-5 is both a valid and reliable measure for assessing PTSD in accordance with the DSM-5 diagnostic criteria (22). Participants were asked to specify their most stressful traumatic

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experience (i.e., the index trauma), and responses were categorized into two groups based on

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trauma type. The first group, “illness-induced PTSD”, consisted of individuals endorsing a serious or life-threatening illness as their index trauma. The second group, “other trauma-induced

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PTSD”, consisted of individuals endorsing all other index traumas (e.g., sexual assault, natural

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disaster, active military combat). PTSD symptoms were assessed with reference to the identified index trauma in the diagnostic interview.

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2.2.2 Other psychiatric disorders. The AUDADIS-5 also assessed depressive/bipolar

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and related disorders (i.e., major depressive disorder, bipolar 1 disorder, dysthymia, manic episode, hypomanic episode), anxiety disorders (i.e., generalized anxiety disorder, specific

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phobia, social phobia, agoraphobia, panic disorder), substance use disorders (i.e., alcohol use disorder, nicotine dependence, drug use disorders), and personality disorders (i.e., schizotypal personality disorder, borderline personality disorder, antisocial personality disorder). The AUDADIS-5 is valid and reliable across psychiatric disorders (22). All psychiatric disorders were assessed on a past-year basis, except personality disorders (lifetime assessment).

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2.2.3 Sociodemographic variables. Age was assessed as a continuous variable and sex (female, male), education (less than high school, high school or equivalent, some college, completed college degree or higher), marital status (married or living with someone as if married, widowed, separated/divorced, single/never married), household income (0-$34,999,

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$35,000+), and race/ethnicity (White, Black, Other) were assessed categorically in accordance

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with prior research (e.g., 23, 24, 25).

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2.2.4 Physical health conditions. The NESARC-III assessed a number of physical health conditions based on respondent self-report of whether they had each condition in the past

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year, and whether this condition was confirmed by a health professional. We based the presence

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of a physical health condition on the latter, more stringent, criteria. We created a continuous variable to assess the number of physical health conditions endorsed. We also categorized

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conditions that are acutely life-threatening (or perceived to be life-threatening; i.e., myocardial

injury) as a separate variable.

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infarction, heart disease, seizure disorder, stroke, any cancer, lung disorder, traumatic brain

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2.2.5 Health-related quality of life. Physical and mental health-related quality of life

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were assessed using items from the norm-based Short Form-12 Health Survey version 2 (SF12V2) included in the NESARC-III. The SF12-V2 is a validated, self-report measure of quality of

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life that was adapted from the second version of the Short Form (36) Health Survey (SF-36 v2; 26, 27). The physical health quality of life summary score was comprised of: physical functioning, role physical, bodily pain, and general health factors. Factors included in the mental health quality of life summary score were: vitality, social functioning, role emotional, and mental health. Lower scores on the SF12-V2 indicate poorer quality of life. 2.3 Analytic Strategy

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First, we assessed the weighted prevalence of illness-induced and other trauma-induced PTSD. Next we assessed weighted prevalence rates and mean scores for all health-related variables among those with illness-induced and other trauma-induced PTSD. Multiple logistic regressions examined the association between any acutely life-threatening condition (reference =

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those without an acutely life-threatening condition) and illness-induced PTSD, in order to assess

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whether these conditions were more likely to be present in participants with illness-induced

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PTSD than in those with other trauma-induced PTSD. An unadjusted model was conducted in addition to a second model adjusting for sociodemographics (i.e., age, sex, race/ethnicity, marital

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status, education, household income). Illness-induced PTSD was our independent variable for the

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second and third analyses, in order to examine whether illness-induced PTSD was associated with greater mental health comorbidity and poorer quality of life compared to other-trauma

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induced PTSD. We used multiple logistic regressions to estimate the relationship between

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illness-induced PTSD (reference = other trauma-induced PTSD) and multiple mental health conditions (i.e., depressive/bipolar and related disorders, anxiety disorders, alcohol use disorder,

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nicotine dependence, drug use disorders, personality disorders) in an unadjusted model and

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model adjusting for sociodemographics. We examined the presence and absence of each mental health condition separately (where statistical power permitted), as well as each composite group

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of mental health conditions (i.e., any depressive disorder, any anxiety disorder, any drug use disorder, any personality disorder) as separate dependent variables. Finally, we conducted multiple linear regressions to estimate the association between illness-induced PTSD (reference = other trauma-induced PTSD) and health-related quality of life. In addition to the unadjusted and sociodemographics-adjusted models, we also estimated a third model adjusting for total number of physical health conditions (i.e., medical morbidity), and a fourth model additionally

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adjusting for mental health conditions. Analyses were conducted in Stata software, version 14 (28), using the Taylor Series Linearization method (29) for variance estimation. 3. Results 3.1 Sample Characteristics

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Table 1 displays the sociodemographic characteristics of illness-induced and other

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trauma-induced PTSD. The total past-year prevalence of PTSD was 4.7% (n = 1,779). Among

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individuals with past-year PTSD, 6.5% of cases were illness-induced (n = 102), compared to 92.9% (n = 1,669) elicited by any other index trauma. The prevalence rate of illness-induced

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PTSD among the entire sample (N = 36,309) was 0.3%. Not included in Table 1, the prevalence

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rate of illness-induced PTSD among any acutely life-threatening condition was 10.7%. 3.2 Physical Health Correlates

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Those with illness-induced PTSD had a higher mean number of physical health

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conditions compared to those with other trauma-induced PTSD (3.91 vs. 2.58) and a higher proportion of acutely life-threatening conditions (45.0% vs. 25.6%). After adjusting for

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sociodemographics, participants with any acutely life-threatening condition had significantly

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increased odds of illness-induced PTSD compared to those without a life-threatening condition (adjusted odds ratio (AOR) = 2.32, 95% confidence interval (CI) [1.30-4.14], p < .01).

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3.3 Mental Health Correlates Table 2 displays the mental health correlates of illness-induced PTSD. Compared to those with other trauma-induced PTSD, individuals with illness-induced PTSD had lower rates of all mental disorders, with the exception of drug use disorders (including cannabis use disorder). Compared to those with other trauma-induced PTSD, individuals with illness-induced PTSD had significantly lower odds of depressive/bipolar and related disorders (AOR = 0.56, 95% CI [0.32-

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0.99], p < .05) and antisocial personality disorder (AOR = 0.30, 95% CI [0.12-0.70], p < .05), but significantly greater odds of cannabis use disorder (AOR = 1.98, 95% CI [1.01-3.89], p < .05), after adjustment for sociodemographics. Post hoc analyses examined whether significant differences in comorbid mental health

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conditions existed between those with illness-induced PTSD and a life-threatening condition

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compared to those with other trauma-induced PTSD with a life-threatening condition. Results

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revealed that those with illness-induced PTSD and a life-threatening condition had a lower prevalence of agoraphobia/panic disorder (9.4% vs. 35.1%). This result was confirmed by

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multiple logistic regressions (adjusting for sociodemographics; reference = those with other

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trauma-induced PTSD and a life-threatening condition). Illness-induced PTSD with a lifethreatening condition was associated with reduced odds of agoraphobia/panic disorder (AOR

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(adjusted odds ratio) = 0.18, 95% CI [0.07-0.45], p < .001), in addition to reduced odds of any

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anxiety disorder (AOR = 0.52, 95% CI [0.29-0.95], p < .05), any personality disorder (AOR = 0.47, 95% CI [0.25-0.89], p < .05), borderline personality disorder (AOR = 0.53, 95% CI [0.28-

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0.99], p < .05), and antisocial personality disorder (AOR = 0.18, 95% CI [0.04-0.79], p < .05).

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3.4 Health-Related Quality of Life

Illness-induced PTSD was associated with lower scores on the physical health-related

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quality of life total score (unstandardized regression coefficient (β) = -4.67, 95% CI [-8.18 - 1.16], p < .05), as well as the physical functioning (β = -4.18, 95% CI [-7.97 - -0.39], p < .05) and bodily pain (β = -4.49, 95% CI [-8.32 - -0.67], p < .05) subscales in unadjusted models. However, after adjustment for sociodemographics and number of physical health conditions, the two PTSD groups did not differ on any dimension of quality of life (see Table 3).

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Post hoc multiple linear regression analyses (adjusting for sociodemographics) examined whether significant differences in quality of life existed between those with illness-induced PTSD and a life-threatening condition compared to those with other trauma-induced PTSD with a life-threatening condition. Results revealed that groups did not differ in health-related quality

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of life; physical health-related quality of life total score (β = -0.76, 95% CI [-6.55 – 5.03], p >

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.05), physical health-related quality of life subscales (β range: -2.45 – 0.26, p > .05), mental

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health-related quality of life total score (β = -1.61, 95% CI [-6.16 – 2.94], p > .05), and mental health-related quality of life subscales (β range: -4.34 – 1.44, p > .05).

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4. Discussion

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To the best of our knowledge, this study represents the first epidemiologic investigation comparing mental health comorbidities and quality of life of individuals with illness-induced

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PTSD with those who meet criteria for PTSD due to more distinct, external traumatic events

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(other trauma-induced PTSD). It is also the first study to assess correlates of illness-induced PTSD by diagnostic interview using DSM-5 PTSD criteria. This study’s findings suggest that

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illness-induced PTSD affects nearly one million U.S. adults annually (i.e., 0.3% of the U.S. 2013

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population; 30), and as suggested by research from our group (12), it may be associated with a unique PTSD symptom profile and demographic distinctions compared to other trauma-induced

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PTSD. This study extends prior findings by examining the correlates of illness-induced PTSD. Results suggest that illness-induced PTSD may be associated with a distinct mental health profile compared to other trauma-induced PTSD. However, mental and physical health-related quality of life did not differ between participants with illness-induced PTSD and those with other trauma-induced PTSD, suggesting that illness-induced PTSD should be considered equally important to identify and treat.

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Of the 1,779 past-year PTSD cases in this nationally representative sample, nearly 7% were illness-induced. The NESARC defines an illness as an index trauma as a “serious or lifethreatening illness”. Thus, the identified prevalence of illness-induced PTSD within the NESARC likely includes a more heterogeneous sample compared to that which would have been

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identified using the more exclusive DSM-5 definition of illness as an index trauma (i.e.,

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“Medical incidents that qualify as traumatic events involve sudden, catastrophic events”; 17, p.

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274). The DSM-5 PTSD criterion A terminology is likely associated with a large underestimation of the prevalence of illness-induced PTSD. This nomenclature has impacted the

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scope of the literature in this area, which largely has focused on catastrophic, homogenous types

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of medical events, with sudden onsets (e.g., cardiovascular events, cancer; individually) rather than chronic, more heterogeneous medical conditions. This may suggest that illness-induced

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PTSD could also be associated with chronic medical conditions, but further investigation is

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warranted in order to support this possibility with confidence. Individuals with illness-induced PTSD had a higher prevalence of any acutely life-

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threatening condition (i.e., myocardial infarction, heart disease, seizure disorder, stroke, any

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cancer, lung disorder, traumatic brain injury) compared to other trauma-induced PTSD. This is unsurprising considering the NESARC criteria for endorsing illness as an index trauma requires

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the experience of an illness that is serious or life-threatening. However, the two groups did not significantly differ in health-related quality of life after accounting for medical morbidity. This finding suggests that the illness-induced group has poorer physical health (driven by the number of comorbid physical health conditions), however they do not differ in mental health-related quality of life compared to those with other trauma-induced PTSD. In addition, individuals with illness-induced PTSD and a life-threatening condition exhibited different mental health

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comorbidities from those with other trauma-induced PTSD and a life-threatening condition, further supporting the distinctiveness of this condition. This finding also suggests that the distinct presentation of illness-induced PTSD may specifically relate to the perception of an illness as one’s most traumatic experience, rather than relating to the experience of a life-threatening

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illness in general.

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Results of the current study suggest that illness-induced PTSD may have a distinct

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presentation of mental health comorbidities that differs from other trauma-induced PTSD. Specifically, illness-induced PTSD was associated with decreased odds of any depressive/bipolar

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disorder or antisocial personality disorder. Depression is very common after acute life-

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threatening illnesses (31, 32), and is associated with increased risk for recurrent illness and mortality in cardiovascular and other diseases (33, 34). One explanation for the lowered risk for

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comorbid depression in illness-induced PTSD compared to other trauma-induced PTSD could be

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a lowered or different genetic or demographic-related risk for psychological disorders generally in illness-induced PTSD. For example, individuals with illness-induced PTSD had a higher mean

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age than those with other trauma-induced PTSD, and prior research has suggested that the risk

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for depression decreases with age (24), as well as that psychological health tends to improve with age (35). In further support, the phenotype of illness-induced PTSD may differ from traditional

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forms of PTSD as prior research by our group has found that participants with illness-induced PTSD were older and had a much later first onset of PTSD symptoms compared to other traumainduced PTSD (12). Similarly, prior research has indicated that PTSD symptom profiles may vary according to the index trauma (e.g., 36, 37). In support, previous research from our group has found evidence that PTSD symptom patterns or severity may differ between illness-induced and other trauma-induced PTSD, with fewer alterations in cognition and mood symptoms (from

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cluster D) found in illness-induced PTSD (12). This may translate to a lower prevalence of comorbid depressive disorders compared to other trauma-induced PTSD. Further, prior research has also indicated that trauma type may play an important role in the comorbid relationship between PTSD and these disorders. For example, Smith, Summers, Dillon, and Cougle (38)

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examined whether correlates of PTSD specifically relate to the PTSD index trauma and found

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that comorbid depression was uniquely associated with experiencing the unexpected death of a

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loved one (AOR = 1.96, 95% CI [1.20-3.20], p < .001) compared to the other trauma types assessed. However, life-threatening illness was not included as an index trauma in these

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analyses, and thus caution is warranted upon interpreting these results.

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With regard to antisocial personality disorder, prior research has suggested that certain trauma-types are specifically associated with this disorder, including childhood trauma/neglect,

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physical trauma, and crime-related trauma (e.g., 39, 40, 41). In addition, results of the National

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Comorbidity Survey-Adolescent Supplement supported a reciprocal relationship between the risk of conduct disorders (which commonly precede antisocial personality disorder; 42) and exposure

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to interpersonal violence, where exposure to interpersonal violence was associated with the onset

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of conduct disorders, and conduct disorders were associated with higher risk of being exposed to interpersonal violence (43). Thus, these traumatic experiences may relate to an increased

PTSD.

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likelihood of classification in the more traditional PTSD subtype as opposed to illness-induced

Moreover, individuals who have experienced traumas other than illness (most particularly interpersonal traumas) tend to exhibit high rates of shame and self-blame (44, 45, 46), which are strongly correlated with depressive, antisocial, and PTSD symptoms (e.g., 44, 45, 47, 48, 49). In support, interpersonal traumas are common among individuals with depression and antisocial

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personality disorder (e.g., 39, 50). It is possible that the lower prevalence of depressive disorders and antisocial personality disorder among illness-induced PTSD is related to lower levels of shame and self-blame among these individuals. However, these characteristics were not assessed by the current study, and thus warrant examination in future investigations.

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Despite a lowered risk for certain psychiatric disorders, illness-induced PTSD was also

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associated with increased odds of cannabis use disorder. Prior research has documented use of

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medical marijuana among individuals with a variety of physical and mental health problems including life-threatening illnesses (such as cancer, multiple sclerosis, amyotrophic lateral

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sclerosis; 51, 52), chronic pain (e.g., 53, 54), and PTSD (e.g., 55), as well as marijuana use for

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self-medication among those with PTSD (e.g., 56). Considering individuals with illness-induced PTSD would have, by definition, experienced a serious or life-threatening illness (and both life-

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threatening illnesses and PTSD have been linked with marijuana use), this may explain the

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association found between illness-induced PTSD and cannabis use disorder. It is possible that individuals who are prescribed marijuana for an illness and who also have PTSD may be more

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likely to have a cannabis use disorder as a result of increased access and self-medication of

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PTSD symptoms. This may be particularly important in the case of illness-induced PTSD, where an individual may be more likely to use marijuana (whether prescribed or not) for self-

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medication in an attempt to reduce primarily somatic-related hyperarousal symptoms (e.g., heart palpitations, gastrointestinal pain). The current study’s finding may suggest the importance of screening for illness-induced PTSD before prescribing medical marijuana and/or screening for cannabis use disorder in the context of illness-induced PTSD. However, further research is warranted to explore this novel finding.

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Although the current study presents unique findings, they must be considered alongside a number of limitations. First, due to the cross-sectional nature of the NESARC, assumptions regarding causality and temporality should not be made. Second, although all individuals with illness-induced PTSD endorsed a serious or life-threatening illness as their index trauma, we

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could not determine which specific illness was the index trauma for the PTSD interview (only

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the category “illness” was recorded). Third, physical health conditions were assessed by self-

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report of diagnoses received from a health professional. Prior research has indicated a high concordance rate between physician-diagnosed and self-reported conditions in some studies (57),

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but poor concordance in others (58). Finally, the NESARC excluded institutionalized individuals

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(i.e., hospitalized individuals) from the survey and because of this, results may not be representative of the most severe cases of illness-induced PTSD.

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Despite these limitations, the current study represents an important contribution to this

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growing body of research by comparing mental health comorbidities and quality of life between individuals with illness-induced PTSD and those with PTSD due to distinct external events in a

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population-based, heterogeneous trauma sample. Results support the notion that illness-induced

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PTSD exhibits unique characteristics from a more traditional conceptualization of PTSD, which may highlight the importance of potential sub-typing of PTSD among future versions of the

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DSM. In addition, this has important implications for the development of targeted interventions for this population. Considering the body of research suggesting symptoms of illness-induced PTSD may be distinct from traditional conceptualizations of PTSD (e.g., 10, 11), and the results of the current study indicating illness-induced PTSD may have unique correlates, current PTSD treatments (targeted at traditional PTSD) may not be the most clinically relevant option. Finally,

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screening in medical settings such as primary care.

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Acknowledgments Funding: This work was supported by [edited out for blind review] Start-Up Funding [edited out

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Table 1 Primary Sample Characteristics Comparing Other-Induced PTSD to Illness-Induced PTSD Past-year PTSD (n = 1,779; 4.7%) Other Trauma-Induced Illness-Induced n (weighted %) 1,669 (92.9%) 102 (6.5%) Sociodemographics Agea 42.08 (0.45) 45.71 (1.75) Sex Females 1194 (68.2%) 54 (54.3%) Males 475 (31.8%) 48 (45.7%) Education Less than high school 286 (16.5%) 19 (14.7%) Completed high school 456 (25.9%) 21 (18.5%) Some college 424 (25.9%) 30 (33.2%) Completed degree 503 (31.6%) 32 (33.5%) Marital status Married/common law 610 (46.1%) 41 (48.4%) Widowed 104 (5.5%) 10 (6.1%) Separated/divorced 467 (23.0%) 24 (19.8%) Single/never married 488 (25.4%) 27 (25.7%) Household income $0-34,999 1,014 (52.3%) 61 (47.7%) $35,000-70,000+ 655 (47.7%) 41 (52.3%) Ethnicity White 940 (68.1%) 59 (71.8%) Black 347 (12.3%) 16 (8.2%) Other 382 (19.6%) 27 (20.0%) Note. PTSD = posttraumatic stress disorder a Reported values represent M(SE)

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Table 2 Logistic Regressions Examining the Association Between Type of PTSD and Mental Health Conditions Past Year PTSD (n = 1,779) Other TraumaInduced 1,669 (92.9%)

IllnessInduced

Illness-Induced

102 (6.5%)

AOR (95% CI) Depressive/Bipolar Disorder 882 (51.8%) 42 (35.5%) 0.51 (0.30-0.87)* 0.56 (0.32-0.99)* Major Depressive Disorder 627 (37.0%) 28 (25.4%) 0.58 (0.34-0.98)* 0.64 (0.37-1.11) Bipolar Disorder 207 (12.7%) 11 (7.3%) 0.54 (0.24-1.23) 0.54 (0.24-1.24) Dysthymia 269 (14.9%) 11 (10.4%) 0.66 (0.32-1.36) 0.67 (0.31-1.46) Anxiety Disorder 846 (51.6%) 48 (44.9%) 0.76 (0.47-1.23) 0.82 (0.51-1.34) Generalized Anxiety Disorder 462 (28.4%) 30 (26.7%) 0.92 (0.52-1.62) 0.95 (0.55-1.66) Specific or Social Phobia 462 (28.9%) 23 (22.5%) 0.71 (0.43-1.18) 0.76 (0.46-1.26) Agoraphobia or Panic Disorder 406 (24.5%) 15 (17.0%) 0.63 (0.30-1.34) 0.68 (0.32-1.46) Alcohol Use Disorder 441 (25.0%) 22 (16.8%) 0.61 (0.35-1.06) 0.61 (0.32-1.17) Nicotine Dependence 676 (40.4%) 39 (36.6%) 0.85 (0.50-1.44) 0.95 (0.60-1.52) Drug Use Disorder 248 (14.7%) 18 (16.9%) 1.18 (0.57-2.42) 1.32 (0.73-2.38) Cannabis Use Disorder 141 (9.0%) 13 (14.3%) 1.68 (0.75-3.74) 1.98 (1.01-3.89)* Personality Disorder 995 (59.0%) 58 (51.6%) 0.74 (0.46-1.19) 0.79 (0.50-1.25) Schizotypal Personality Disorder 506 (30.3%) 29 (22.9%) 0.68 (0.40-1.18) 0.72 (0.41-1.27) Borderline Personality Disorder 912 (54.2%) 56 (50.3%) 0.86 (0.53-1.37) 0.95 (0.61-1.48) Antisocial Personality Disorder 222 (13.6%) 9 (5.1%) 0.34 (0.15-0.79)* 0.30 (0.12-0.70)** Note. Reference group is those with other trauma-induced PTSD; PTSD = posttraumatic stress disorder; OR = unadjusted odds ratio; AOR = adjusted for sociodemographics (age, sex, education, marital status, household income, race/ethnicity). CI = confidence interval; Drug use disorders (i.e., sedative, cannabis, opioid, cocaine, stimulant, hallucinogen, inhalant/solvent, club drug, heroin, other drug) with n < 5 for illness-induced PTSD were excluded from table but included in condition categories. n(%) represent those who have each condition among other trauma-induced and illness-induced PTSD. *p < .05, **p < .01 n (%)

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Table 3 Linear Regressions Examining the Association Between Type of PTSD and Quality of Life Past-year PTSD (n = 1779) Other IllnessTraumaIllness-Induced Induced Induced 1,669 102 n(%) (92.9%) (6.5%) Quality of Life M (SE) Unstandardized Regression Coefficient (95% CI) Model 1 Model 2 Model 3 Norm-Based 41.24 40.46 Mental -0.78 (-3.85-2.29) -0.19 (-2.94-2.56) -2.13 (-4.87-0.62) (0.34) (1.55) Summary Scale 45.97 43.87 Vitality -2.11 (-4.90-0.69) -0.46 (-2.75-1.84) -1.13 (-3.48-1.21) (0.36) (1.39) Social 38.74 41.52(0.41) -2.78 (-6.54-0.97) -1.44 (-4.82-1.93) -3.14 (-6.42-0.15) Functioning (1.92) Role 39.96 38.99 -0.97 (-4.50-2.56) 0.30 (-2.84-3.44) -1.11 (-4.41-2.19) Emotional (0.35) (1.81) 42.10 40.16 Mental Health -1.94 (-5.62-1.74) -1.07 (-4.44-2.30) -2.89 (-6.15-0.38) (0.38) (1.84) Norm-Based 45.05 40.38 -4.67 (-8.18 - Physical -1.78 (-4.60-1.05) -1.67 (-4.54-1.19) (0.44) (1.72) 1.16)* Summary Scale Physical 45.88 41.70 -4.18 (-7.97 - -1.58 (-4.80-1.63) -1.86 (-5.09-1.37) Functioning (0.44) (1.92) 0.39)* 43.14 40.22 Role Physical -2.92 (-6.33-0.49) -1.21 (-4.02-1.61) -1.75 (-4.63-1.13) (0.37) (1.69) 42.28 37.79 -4.49 (-8.32 - Bodily Pain -1.62 (-5.40-2.16) -1.90 (-5.61-1.81) (0.48) (1.92) 0.67)* General 42.12 38.06 -4.06 (-8.35-0.22) -1.36 (-5.00-2.27) -2.00 (-5.78-1.78) Health (0.46) (2.14) Note. Lower mean scores are indicative of poorer quality of life; PTSD = posttraumatic stress disorder; CI = confidence interval; Model 1 = unadjusted; Model 2 = adjusted for sociodemographics (age, sex, education, marital status, household income, race/ethnicity) and number of physical health conditions; Model 3 = adjusted for sociodemographics, number of physical health conditions, and mental health conditions (depressive/bipolar disorders, anxiety disorders, substance use disorders, personality disorders) *p < .05