Learn about the connection between trauma and immune function and the implications for nursing care.
- Trauma has a significant influence on physical health.
- Re-traumatization and chronic stress trigger inflammation and impair immune function, which over time can trigger or worsen diseases.
- Substance Abuse and Mental Health Services Administration has established ten trauma informed–care implementation strategies, six key principles, and four assumptions (realize, recognize, respond, and resist).
Learning Objectives
- Differentiate between acute stress disorder and post-traumatic stress disorder.
- Analyze how trauma exposure relates to chronic inflammation and the development of autoimmune and cardiometabolic diseases.
- Integrate trauma-informed screening and communication strategies into nursing assessments and care planning.
Reflective Learning Question 1:
How could recognizing acute stress disorder during hospitalization improve the timing and effectiveness of nursing interventions?
Reflective Learning Question 2:
What screening or communication practices could you use to uncover trauma histories while maintaining patient safety and trust?
No relevant financial relationships were identified for any individuals with the ability to control content of the activity.
Expiration: 2/1/29
1.25 ANCC contact hours
TRAUMA CHANGES US. This powerful emotional experience of terror or stress affects biology and immune function, reminding us of the connection between the mind and body. According to Katrinli and colleagues, trauma increases the risk for poor health outcomes, including cancer, diabetes, and other inflammatory chronic autoimmune diseases. The younger the person who experiences the trauma, the more significant the changes to biology over time.
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as an event or series of events perceived as potentially harmful on various levels—physically, socially, financially, or emotionally. Events that may create unrelenting high stress include abuse; neglect; loss of parents to death or incarceration; interpersonal violence; family caregiver mental health issues; and concerns in the community such as violence, war, natural disasters.
SAMHSA, Sun and colleagues, and Bookwalter and colleagues have described trauma duration and later re-traumatization as having compounding impacts on health. The traumatic event can have lasting effects on physical health, mental health, and emotional, social, and spiritual well-being. Impaired neurotransmitter levels resulting from early trauma can predict issues with mental health later in life. The mental health issues associated with trauma are mediated through biological changes such as inflammation.
Researchers studying the pathophysiology of traumatic stress over the past 20 years have found a clear correlation to immune function, but the underlying mechanisms aren’t completely understood. Knowledge of the physical health consequences of the complex cascade of biological responses to trauma and their possible pathways of action can help nurses provide trauma-informed care.
Stress response
According to Sun and colleagues, post-traumatic stress disorder (PTSD) and acute stress disorder (ASD), the two most common trauma diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (DSMV-TR), have increased the medical burden worldwide. PTSD occurs over time after a significant traumatic experience. ASD has symptoms similar to PTSD but occurs immediately (up to 4 weeks) after the trauma. Because ASD serves as a predisposing factor for PTSD, therapy or other interventions should be provided within that early window.
The stress response (fight or flight) triggers a surge of hormones, such as adrenaline and cortisol, to react quickly to a threat. Heart and respiration rates increase, blood pressure rises, and oxygen surges to the muscles. The brain becomes focused and hyperaware of danger in the environment as it floods with oxygen. Nonimmediate normal functions (like digestion) cease, rechanneling oxygen or nutrients to the brain and muscles. Essential immune maintenance diminishes to manage the perceived danger. For individuals who experience frequent waves of fight-or-flight responses, their bodies operate in danger alert mode for long periods, resulting in extended instances of immune dysfunction.
Many individuals who experience trauma live in a chronic stress response with increased vigilance of the environment and more frequent physical overreactions to stress. The amygdala, the center for emotional regulation, can remain chronically hyperactive years after the trauma. Situations that remind the person of the trauma lead to another wave of fight-or-flight chemicals, resulting in feelings of panic.
A person who’s experienced trauma may have a smaller hippocampus (the area of the brain for learning, memory, and controlling the stress response). According to a functional magnetic resonance imaging study by Devignes and colleagues, each recurrence of flashbacks, intrusive memories, or re-traumatization further impacts hippocampus function. The prefrontal cortex becomes unable to regulate emotions or calm the fight-or-flight response. Over time, immune function becomes impaired, leading to inflammation and disease.
The biological response and its effects on health depend heavily on a person’s perception of the trauma and their emotional and cognitive responses. The more powerful the perception of the trauma, the greater the damage to immune function.
Increased incidence of disease
According to the UCSF Center to Advance Trauma Informed Health Care, individuals who’ve had several adverse childhood experiences are 1.2 times more likely to develop diabetes, 2 to 2.3 times more likely to have a stroke or acquire heart disease, more than 3 times more likely to have chronic respiratory disease, and 10 times more likely to experience substance use disorder. An increase in autoimmune diseases such as Type 1 diabetes, lupus, Crohn’s disease, ulcerative colitis and other irritable bowel diseases (IBD), multiple sclerosis (MS), celiac disease, and rheumatoid arthritis also occurs in this population. A rise in obesity also is linked to inflammation.
Autoimmune diseases occur when an overactive immune system attacks the body’s own tissue, unable to differentiate them from foreign proteins or pathogens. Bookwalter and colleagues’ study of over 120,000 military personnel found a 58% higher incidence of autoimmune diseases such as rheumatoid arthritis, lupus, MS, and IBD in those with a history of PTSD. Ke and colleagues described PTSD as a risk factor for dysregulated immune function and early death.
Inflammation
The connection between trauma and physical health becomes clearer when it’s understood that inflammation serves as a mechanism of illness. Inflammatory processes result from stress and trauma, impair immune function, and trigger disease.
Inflammation operates as the body’s defense response to disease or injury. However, chronic inflammation contributes to the development of heart disease, stroke, obesity, cancer, diabetes, and Alzheimer’s disease. Beurel and colleagues suggest that inflammation may be a disease modifier, increasing susceptibility to depression, and that a bi-directional relationship exists between trauma and inflammation.
Not everyone who experiences trauma develops PTSD. Factors such as perception of the event, support, ability to process, and resilience all influence healing. However, according to Katrinli and colleagues, people already suffering from chronic inflammation may have an increased chance of developing PTSD.
Extensive studies (including by Bookwalter and colleagues, Katrinli and colleagues, and Sun and colleagues) of the physiological consequences of stress and trauma have found that stress triggers a dysregulation of the sympathetic adrenaline–medulla (SAM) and hypothalamic–pituitary–adrenal (HPA) axes. Abnormal circadian rhythms and high cortisol levels result in elevated levels of cytokines, protein messengers that trigger inflammation. This leads to a chronic underlying inflammatory process that, over time, promotes the development of cancer, cardiovascular disease, asthma, and obesity. According to Koirala and colleagues, these immunological changes have even become biomarkers to aid in the diagnosis of PTSD. (See How SAM and HPA work.)
How SAM and HPA work
The sympathetic adrenaline–medulla (SAM) process works via the nervous system, releasing adrenaline and norepinephrine to prepare the body for stress.
The hippocampus activates the hypothalamic–pituitary–adrenal axis (HPA) by emitting corticotropin-releasing hormone and triggering the pituitary gland to discharge adrenocorticotropic hormone, which travels to the adrenal glands. With the release of cortisol, the body moves into high alert.
Epigenetics
Epigenetics (the study of how internal or environmental factors trigger genes to express or remain dormant) serves as another pathway to illness through trauma. Our behaviors and cognitive processes can impact gene expression. For example, as reported in a meta-analysis by Sun and colleagues, some individuals with PTSD have DNA methylation levels in the blood 6 to 7 times higher than those without PTSD.
DNA methylation alters gene expression and promotes inflammation by increasing pro-inflammatory cytokines. Stress experienced early in life, especially if it’s severe, can lead to chronic high-stress chemicals, inflammation, and long-lasting changes to gene expression. HPA disorder, prolonged impaired immune function, and chronic inflammation all increase the risk of a gene shedding its protective protein and triggering any disease the individual is genetically predisposed to develop. In short, as described by Sun and colleagues, if a person has a genetic risk for an autoimmune disease such as rheumatoid arthritis, the chances of those genes kicking in and triggering the disease increase if the person experiences early or lasting trauma.
Sleep
According to Yeh and colleagues, many individuals who’ve experienced trauma encounter persistent sleep disturbances and hyperarousal. They may report difficulty falling asleep, early awakening, restless sleep, and nightmares. Because most immune system maintenance occurs in deep stages of sleep, the presence of disturbances in these stages may lead to further immune function impairment.
Yeh and colleagues also describe how sleep deprivation amplifies inflammation markers (cytokines such as Interleukin-6), adding to the chronic inflammatory states of those who’ve experienced trauma. These markers are associated with the development of cardiovascular disease, diabetes, and autoimmune disease. Sleep medications or substances used by patients to self-medicate can lead to misuse and the need for increased amounts for effect. Together, trauma and poor sleep create a vicious cycle: Disrupted rest worsens inflammation and trauma impairs sleep, perpetuating risk for chronic disease across the lifespan.
Gut microbiome
The gut microbiome (bacteria, fungi, and other microbes in the digestive system) produces essential enzymes, neurotransmitters, and vitamins for health and proper immune function. Many diseases associated with an out-of-balance gut biome are characterized by chronic low-grade inflammation, adding to the consequences of trauma. As described by Ke, the gut microbiome plays a significant role in calming or activating the immune system’s inflammatory responses and may contribute to PTSD. Stress, depression, and anxiety modulate the activity and composition of the microbiome; this interaction is bidirectional. Ke also notes that an unbalanced gut microbiome can predict increased severity of PTSD development after trauma. Similar to trauma, an unbalanced microbiome is associated with inflammation, immune dysfunction, and auto-immune disease.
Implications for trauma-informed nursing care
According to the World Health Organization, approximately 70% of people worldwide will experience a potentially traumatic event during their lifetime. Given this fact and the understanding of how the body responds to trauma and its long-term effects, nursing care must include trauma-informed practices, which take patient-centered care from “What’s wrong?” to “What happened?” As the largest number of healthcare professionals, nurses can impact how patients receive care.
A trauma-informed approach recognizes and responds to signs of trauma in all patients to provide better, more effective care. SAMHSA has established ten trauma informed–care implementation strategies, six key principles, and four assumptions (realize, recognize, respond, and resist). (See Domains and principles.)
Domains and principles
The Substance Abuse and Mental Health Services Administration (SAMHSA) has established the following ten domains designed to help healthcare systems implement trauma-informed care.
2. Governance and leadership
3. Cross sector collaboration
4. Financing
5. Physical environment
7. Screening, assessment, and treatment services
8. Progress monitoring and quality assurance
9. Policy
10. Evaluation
In addition, SAMHSA’s trauma-informed approach includes six key principles that healthcare systems should embody when delivering care. Consider the following definitions and accompanying implementations:
- Emotional safety—Ensure patients feel emotionally secure and respected by establishing rapport and asking about preferences.
- Physical environment—Take steps to keep the physical environment calm, welcoming, and safe. Reduce noise levels and provide private spaces.
- Comfort measures—Offer comfort items such as blankets, pillows, or soft lighting.
- Trust—Establish a trusting relationship with patients through honest and open communication.
- Transparency—Remain transparent about procedures, treatments, and care plans.
- Clear communication—Use clear, direct, straightforward language when communicating with patients. Explain procedures and what to expect.
- Active listening—Practice active listening to understand the patient’s concerns and experiences.
- Consistency—Remain consistent and follow through on promises to build trust.
- Support systems—Encourage connections with peer support systems, such as support groups or therapy.
- Support resources—Provide information about and referrals to support groups, counseling services, and other resources.
- Support groups—Encourage patients to participate in peer support groups where they can share their experiences and help each other.
- Peer navigators—Use peer navigators or mentors who have lived experience of trauma to support patients.
- Patient involvement—Involve patients in their care decisions and respect their autonomy.
- Interdisciplinary collaboration—Work collaboratively with other healthcare professionals to provide comprehensive care.
- Patient empowerment and participation—Empower patients by giving them choices and control over their care. Involve patients in their care planning and decision-making processes. Offer choices whenever possible.
- Informed consent—Always obtain informed consent and explain the patient’s rights. Ensure that patients are fully informed about their options and the implications of their choices. Beyond signed consent for procedures, also ask for permission to touch patients. Some patients have experienced force and violence and asking permission to touch clarifies intent for the patient. Something as routine as inserting an I.V. may require holding the patient’s arm and requires verbal consent.
- Cultural sensitivity—Remain aware of and sensitive to cultural, historical, and gender-related issues that may impact a patient’s experience of trauma.
- Personalize care—Tailor care to meet each patient’s unique needs.
- Cultural competence—Be aware of and sensitive to the patient’s cultural background, beliefs, and practices.
- Inclusive language—Use inclusive and nonjudgmental language in all interactions.
Source: Cannon and colleagues 2020
Four assumptions
Realize the widespread impact of trauma and the various potential pathways to recovery. A trauma-informed approach to the delivery of nursing care includes an understanding of trauma and an awareness of its impact across settings, services, and populations. This also involves understanding that trauma can impact individuals across the lifespan with emotional, behavioral, physical, developmental, cognitive, interpersonal, and spiritual ramifications. Trauma (physical, emotional, and psychological) and its long-term effects on health are common and may be a part of many people’s histories, including patients, families, peers, and staff members.
Recognize the signs and symptoms of trauma in your clients, patients, family members, and co-workers. Screening and respectful assessment (using many of the available valid tools) of the patient’s trauma history allow nurses to develop care plans tailored to a patient’s specific trauma experience and provide the appropriate resources. Organizations must educate the healthcare workforce to recognize the outward signs of trauma.
Respond by fully integrating trauma knowledge into micro and macro healthcare system-wide practices, policies, and procedures. This includes increasing awareness about the importance of trauma-informed care within the healthcare system and implementing programs to increase awareness about the impact of trauma on health. After establishing policies and procedures, work to ensure that all healthcare staff receive ongoing training in trauma-informed care principles and practices.
Resist the re-traumatization of clients, patients, staff, and family members. Sensitive interactions include creating a safe environment by remaining mindful of the potential for re-traumatization in interactions, potential triggers, and coercive procedures. Taking a patient-centered approach to minimize triggers and stressors helps to build trust and sustain a safe environment. Respond to patient preferences with respect to touch, space, and interactions.
Build a strong framework
The literature continues to link trauma to many physical, behavioral, and mental health conditions seen in all sectors of healthcare. If left untreated, trauma can contribute to life-altering disease processes. Trauma-informed care serves as a foundational framework to help healthcare systems and nurses provide a safe environment that prevents re-traumatization of patients, staff, family members, and populations. Globally, nurses can play a vital role in implementing necessary changes to ensure safety.
The authors are professors at Austin Peay State University in Clarksville, Tennessee. Debra Rose Wilson is also on the faculty at Walden University in Minneapolis, Minnesota.
American Nurse Journal. 2026; 21(2). Doi: 10.51256/ANJ022606
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Key words: trauma, physical health, trauma-informed-care
American Nurses Association is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.
