Adults with lupus who report having had adverse childhood experiences (ACEs), such as abuse, neglect and household challenges, report higher disease activity, depression and poorer overall health compared to those without such experiences, according to a study by researchers at UC San Francisco.
"Our results support the notion that stress in the form of ACEs may be a factor in poor health in systemic lupus, both in disease development and in more severe outcomes," said lead author Kimberly DeQuattro, MD, a clinical fellow in rheumatology at UCSF. "These findings are a call to action to focus efforts on ACE prevention in childhood, as well as clinical and mental health interventions that foster resilience in adulthood."
The findings appear online May 9, 2019, in Arthritis Care & Research.
Systemic lupus erythematosus is an autoimmune disease in which the immune system attacks the body's own tissues, causing widespread inflammation and tissue damage in affected organs. Lupus is influenced by genetics and the environment, with stress acting as a potential trigger of disease onset and flares, and can lead to chronic disability.
Studies have shown that a large percentage of adults have had adverse childhood experiences. According to the U.S. Centers for Disease Control and Prevention, ACEs have been linked to risky health behaviors, chronic health conditions, low life potential and early death. They also are believed to be a risk factor for autoimmune diseases such as lupus.
In the Arthritis Care & Research study, DeQuattro and her colleagues surveyed 269 lupus patients in the California Lupus Epidemiology Study (CLUES) who completed the ACE questionnaire, a 10-item survey covering abuse, neglect and household challenges. These patients were compared to 6,107 participants from the 2015 California Behavioral Risk Factor Surveillance System (BRFSS), which also includes an ACE questionnaire. The researchers then examined five patient-reported outcomes (lupus flares, damage, depression, physical function and quality of life) with three physician-assessed measures (lupus flares, damage and severity indices) made during an in-person study visit with the patients.
Overall, adverse childhood experience levels were similar for lupus patients and Behavioral Risk study respondents. In lupus patients, 63.2 percent self-reported at least one ACE, and 19.3 percent had at least four ACEs. ACEs were more prevalent in those who were older, female, Latino or African American, without college degrees, and with lupus nephritis (kidney inflammation from lupus).
In adjusted models, more experience of abuse, neglect and household challenges were associated with worse self-reported lupus activity, depression and health status. For example, those with more than four ACEs reported nearly double the disease activity scores of their non-ACE exposed peers (13.1 points to 7.7). These findings were not significantly associated with physician-assessed lupus activity, damage or severity.
"This work in lupus patients supports more broadly the body of studies on adversity and trauma in childhood that have found a link between ACEs and health," DeQuattro said. "Our next steps are to look at other types of stress and trauma, how the body responds, and how they relate to lupus outcomes."
The researchers emphasize the need for prevention of adverse childhood experiences and promotion of safe, stable, nurturing relationships and environments for children. Clinicians also should regularly screen lupus patients for ACEs, along with depression and overall perceived health status, regardless of disease status, the researchers said. It may be more beneficial to screen near the time of diagnosis to identify those at higher risk for poor outcomes.
Co-Authors: Senior author Jinoos Yazdany, Laura Trupin, Jing Li, Patricia Katz, Cristina Lanata, Edward Yelin, Stephanie Rush, Lindsey Criswell and Maria Dall'Era, of UCSF; and Louise Murphy, of the U.S. Centers for Disease Control and Prevention.
Funding: The study was supported by CDC 5U01DP005120; NIH/NIAMS P30AR070155, P60AR053308, 2R01AR056476, T32AR00730439; Rheumatology Research Foundation Scientist Development Award 128849A, Robert L. Kroc Chair in Rheumatic and Connective Tissue Diseases; Robert Wood Johnson Investigator Health Policy Award; and Russell/Engleman Medical Research Center for Arthritis.
Disclosures: The authors report no conflicts of interest.
About UCSF: UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals - UCSF Medical Center and UCSF Benioff Children's Hospitals in San Francisco and Oakland - as well as Langley Porter Psychiatric Hospital and Clinics, UCSF Benioff Children's Physicians and the UCSF Faculty Practice. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area. UCSF faculty also provide all physician care at the public Zuckerberg San Francisco General Hospital and Trauma Center, and the SF VA Medical Center. The UCSF Fresno Medical Education Program is a major branch of the University of California, San Francisco's School of Medicine. Please visit http://www.ucsf.edu/news.
Arthritis Care & Research