Background/Purpose: Autoimmune diseases, including rheumatoid arthritis (RA) and systemic lupus erythematosus, are 2- to 3-fold more common among those with post-traumatic stress disorder (PTSD) than among matched controls.  In US Armed Service personnel, PTSD is more prevalent among individuals with mild traumatic brain injury (TBI).  For both PTSD and TBI there are immune changes that might predispose to autoimmune disease.  We undertook this study in US veterans to investigate potential differences in risk of autoimmune rheumatic illness for TBI patients with versus PTSD those without PTSD.

Methods: We studied a cohort of 229 subjects (137 with PTSD)  followed in a US Department of Veterans Affairs TBI clinic.  Diagnoses were gathered from the electronic medical record.  Clinical diagnosis of a rheumatic autoimmune disease was confirmed by chart review.  Each subject with RA was evaluated for the 2010 ACR/EULAR RA Classification Criteria. We determined anti-CCP and rheumatoid factor by ELISA, anti-ENA by BioPlex and ANA by indirect immnofluorescence in a randomly selected subgroup of 40 veterans with TBI (20 with PTSD and 20 without PTSD), and without a prior diagnosis of RA, SLE, APL, or myositis.

Results: We found 11 of 137 (8%) TBI/PTSD subjects had RA.  Each of these 11 met the 2010 ACR/EULAR criteria.  Meanwhile, only 2 of 92 (2.1%) of those with TBI without PTSD had RA.  Other rheumatic autoimmune disease in the PTSD/TBI group included polymyositis (3), SLE (1), undifferentiated connective tissue disease (1), and primary APL (1).  Thus, a total of 17/137 (12.5%) in the PTSD/TBI group had a rheumatic autoimmune disease.  Among those with only TBI, there were only 4/92 (4.3%) patients with a rheumatic autoimmune disease. This difference (17/137 versus 4/92) was statistically significant (p=0.02, Fisher’s exact test).  In the subgroup with serology, 6/20 sera from PTSD/TBI were ANA positive, while only 1/20 from TBI alone was ANA positive. Concerning anti-ENA, among PTSD/TBI subjects 1 had anti-Ro/SSA, one had anti-RNP and one had anti-RNP and anti-dsDNA.  No TBI alone subjects had anti-ENA. Low positive RF was common but increased among those in the PTSD/TBI subgroup as compared to TBI alone (16/20 versus 10/20, p=0.04, Fisher’s exact test).

Conclusion: There is an increased prevalence of autoimmune rheumatic disease, in particular rheumatoid arthritis, and positive rheumatic autoantibodies in TBI subjects with PTSD compared to those without PTSD.  We conclude that TBI and autoimmunity are not associated, while autoimmunity – both clinically manifest and silent – is associated with PTSD.  Studies investigating causality and mechanism are indicated in this at-risk population.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/association-of-rheumatic-autoimmune-disease-including-rheumatoid-arthritis-with-post-traumatic-stress-disorder-but-not-traumatic-brain-injury-in-veterans/