Dr. Ida-Arlaine Fonkoue

Exploring the Link Between Trauma, PTSD, and Cardiovascular Disease

|
Courtney Grace-Anderson, MS
10 minutes

For Ida Tchuisseu Fonkoue, MD, PhD, MSCR, her research on cardiovascular disease (CVD) risk and post-traumatic stress disorder (PTSD) in her Neurobiology of Emotion, Sleep and Trauma (NEST) lab stems from personal experience.

“In Cameroon, I grew up with three siblings who suffered from sickle cell disease,” she says. “They have all passed away now. I didn't have a good understanding of the disease when I was younger, but when I started medical school, I began to understand the ‘why’ behind their constant pain and ultimately death.”

She watched her father go through many sleepless nights because of his children’s pain. He became accustomed to being in crisis-readiness mode with Dr. Fonkoue’s younger sister, the sibling that survived sickle cell the longest, whenever the disease would cause flare ups and a vaso-occlusive crisis. In short, she witnessed him experience chronic stress.

Later, while pursuing her PhD at Michigan Tech University, Dr. Fonkoue started working in a lab studying the effect of mental stress on the fight or flight system. She observed how acute mental stress in the lab increased the fight or flight response. As she learned more about how mental stress influences blood pressure, sleep, and cardiovascular health, she realized something important: “I know someone living with chronic stress and lack of sleep,” she shares. It was her father. She started to wonder, thousands of miles away from him, what role had the constant stress caused by his children’s health played in the diagnosis of hypertension he had received years prior?

Her father passed away suddenly from a heart attack at the age of 69 when she was completing her PhD studies. However, it wasn’t until she started her postdoctoral fellowship at Emory University studying the link between PTSD and CVD in post-9/11 veterans that some dots started to connect.

According to Dr. Fonkoue: “To be diagnosed with PTSD, you need to have experienced a traumatic event. So, what if my sister's earlier vaso-occlusive episodes, especially the one that led to a stroke and a coma, was the traumatic event for my father?” She believes that each time her sister had another crisis, regardless of the outcome, her father relived that traumatic event.

“It slowly became clear to me that when my sister went into that three-day coma after a vaso-occlusive crisis, it left my father —  and, frankly, all of us — with an undiagnosed case of PTSD. And all her subsequent hospital stays became triggers,” she explains. “My father couldn't sleep when my younger sister was in pain. He would go to work sleep deprived, but couldn't focus there.”

While studying PTSD at Emory, Dr. Fonkoue came to deeply understand not only PTSD but also what might have physiologically led to her father’s heart attack.

Today, her research focuses on PTSD, sleep, and risk of CVD. When she looks back, Dr. Fonkoue now recognizes the harmful combination of lack of sleep and chronic stress on her father’s health, which is where her research journey started. 

Focusing on trauma-exposed women 

While completing her postdoctoral fellowship, Dr. Fonkoue studied veterans diagnosed with PTSD at the Atlanta Veterans Affairs hospital. The study team used a questionnaire called the Combat Exposure Scale to gauge how much combat exposure their participants had. A higher score on that questionnaire indicates greater exposure to combat stressors. Men tended to have higher scores, while women had lower scores or reported no combat exposure. Yet men and women veterans alike suffered from PTSD. She realized then that women in the military might have a different cause of PTSD than men.

“Research shows that for many women veterans, PTSD is caused by interpersonal trauma they experienced during their service, such as Military Sexual Trauma (MST), rather than combat. The Department of Veterans Affairs and other health organizations recognize MST as a major cause of PTSD and related mental health challenges,” she says.

Dr. Fonkoue realized that women in and outside of the military shared a common vulnerability to interpersonal trauma such as physical abuse, sexual abuse, emotional abuse, neglect, bullying, witnessing violence, and domestic violence. And, while women can experience trauma at any age, studies show that many women experience interpersonal trauma at younger ages. She decided then, at the end of her postdoctoral fellowship, to focus her future research on women with PTSD, particularly young adult women (18 to 40 years old).

That pivot put her onto the path she is on today.

Uncovering risk factors of CVD in young adult women 

In her current research, Dr. Fonkoue is comparing the behavioral, biological, and physiological changes happening in young adult women (18 to 40 years old) diagnosed with PTSD to women without a diagnosis of PTSD — all of whom have been exposed to trauma, whether it's interpersonal or not. She compares both groups of women because not everyone who experiences a traumatic event goes on to develop PTSD.

So far, her work has uncovered that young women with PTSD, in addition to poor sleep quality, already show signs of unhealthy blood vessels and impaired nervous system control of the heart. Their blood vessels are getting stiffer and their parasympathetic (rest and digest) system is failing at keeping heart rate and blood pressure in the major arteries low. All these changes are well known risk factors for developing CVD that are not often seen in women at this life stage — that is, before menopause.

It is known that high levels of endogenous estrogen (particularly estradiol), provide a protective effect against CVD in young adult women who haven’t yet reached menopause (premenopausal women). This positive effect of estradiol on blood vessels, the heart, and inflammation are lost during the transition to menopause, when the risk of CVD increases significantly in women. While premenopausal women are generally at a lower risk for heart disease than men of the same age, mental health disorders such as PTSD can disrupt the protective effects of estradiol and increase CVD risk.

For that reason, Dr. Fonkoue also measures estradiol levels in the blood of the women she studies. She wants to determine if young women who have PTSD show a marked decrease in estradiol levels compared to women without the disorder. So far, she has published data showing that it is the case. Her next step is to study how this might affect the heart, the blood vessels, and the nervous system.

“I want to see whether it's the decline in the blood level of estradiol and/or the poor sleep that serve as a bridge between PTSD and these risk factors of CVD we are seeing in these women,” she explains. “Identifying that bridge that can be targeted with an intervention is my next step.” Her long-term goal is to find interventions, particularly non-pharmacological ones, that can slow down or stop the path to early CVD caused by PTSD in women who haven’t even reached menopause yet.

Finally, Dr. Fonkoue found out that about two-thirds of the women in her study report experiencing interpersonal trauma, such as domestic violence or rape. This finding led her to an important question: “Does the type of trauma that caused PTSD matter when it comes to CVD risk? Do other potentially traumatic events such as a car accident, being in a war, or dealing with a serious disease cause behavioral, biological and physiological changes in women similar to interpersonal trauma?” She wants to find out whether all types of traumas affect the heart, blood vessels, the nervous system, estrogen levels and sleep the same way.

An unexpected career path trajectory

Prospective physical therapy students considering a career in research or primary care may wonder about how distinct research paths come to take shape. Dr. Fonkoue’s view is that it’s important to accept how one’s plans can often be just that: plans. Sometimes life steers a person down an unexpected course.

“Contrary to many people — who have a five-year plan or ten-year plan — I did not see myself doing what I'm doing right now,” she shares. “In fact, when I started studying women with PTSD, I experienced significant emotional distress each time I read the traumatic stories our participants shared, especially things that happened to them in their childhood. It broke me!” As a result, she wasn’t sure she was going to keep pursuing this line of research.

“I felt like I was taking on too much,” she says. “Of course, I am a trained physician. But I didn’t know if I would be able to or wanted to carry the weight of these stories. In sum, I never planned for what I'm doing today, but I know that, as long as God keeps me on this path, He will strengthen me.”

Dr. Fonkoue actually saw herself working with patients every day as a physician, not as a researcher. When asked what guided her toward this unexpected path, she credits her work to her lived experience and her ability to connect with people through their stories.

“My life and my ability to connect with people and their story is why I study PTSD today,” she says. “Because although it was difficult and I almost wanted to run away, at the same time I couldn't look away, and I couldn’t stop talking about the fact that PTSD is not all in the head. My people skills have actually served me in my career beyond my clinical skills.”

For this work, it is critical that participants and patients feel safe, seen, and able to trust researchers and providers. As for the physical therapy students who are considering entering research, she has some advice: “I hope you get into research for the right reason,” she shares. “I hope it's not for recognition, for accolades, for anything external. I really hope it's because you feel a connection with the work that you do, the questions you are asking, the disease or the people you study, and not because it's a hot topic right now or any other reasons that only serve you.”

How her research may influence the way physical therapists consider mental health in patients' care

When asked how her findings may change how providers approach patients, Dr. Fonkoue mentions the interconnection between mental health and physical health. “People are often surprised that I conduct research at the intersection of mental health and cardiovascular health in the Division of Physical Therapy at the University of Minnesota,” she says.

“Imagine that you are a physical therapist treating a patient in cardiac rehabilitation after a heart attack," she explains. “That heart attack could be the traumatic event that leads to PTSD or other mental health conditions. Therefore, psychosocial support should be an integral part of your holistic plan of care and education for this patient, if you want to ensure adherence and satisfactory progress. Research, like the kind I conduct, highlights the importance of interdisciplinary communication for optimum patient care. The physical therapist, the cardiologist, the primary care physician, and hopefully a mental health provider would collaborate with other rehab team members to ensure all care is coordinated for the patient.”

She continues: “If someone had a prior heart attack, and now they experience heartburn, chest heaviness, or feel like their heart is beating too fast during exercise, they may fear the possibility of another heart attack. They may live in a constant state of fear and stress that should be addressed right away because it can seriously hinder recovery and return to everyday activities."

Dr. Fonkoue points how important it is for the physical therapist to work to “rewire” the patient’s brain — how they think about their past health events and the symptoms — so that they are not afraid to exercise or complete movements as prescribed.

While growing up in Cameroon, Central Africa, Dr. Fonkoue saw firsthand the application of the African proverb, “It takes a village to raise a child.” She believes that this proverb should apply to healthcare as well. “It should take a village to heal a patient, holistically.”

See below Dr. Fonkoue’s recent lab publications on cardiovascular risk in young women