Psychiatric disorders endorsed by trauma-exposed premenopausal women enrolled in a cardiovascular research study: a 2-year report

Abstract

Introduction

Women are more likely than men to experience interpersonal trauma, with 1 in 3 women affected globally. This paper aims to give a 2-year report of the demographics, trauma history [i.e., non-interpersonal and interpersonal including adverse childhood event (ACEs)] and psychiatric disorders endorsed by premenopausal women screened for our cardiovascular research study.

Methods

Premenopausal women were recruited from the Twin-Cities area using flyers. Interested participants were screened for this study via REDCap. Age, race, history of psychiatric disorders, menopausal status, contraceptives, and current medications were collected. Participants who met the eligibility criteria were enrolled and completed additional questionnaires focusing on trauma exposure and mental health.

Results

The first 2 years our study was open to accrual, a total of 447 premenopausal women were screened. The majority (~ 71%) of our participants were between 18 and 30 years old. Among the 447 women, 35% reported a diagnosis of posttraumatic stress disorder (PTSD), while 46% reported depression and 53% an anxiety disorder, according to DSM-5. Further, we found that women between the ages of 21–25 years reported the most (23%) psychiatric disorders, mainly PTSD. The main type of trauma reported was interpersonal trauma (~ 62%), of which 76% were ACEs.

Conclusion

Among the trauma-exposed women enrolled in our study, the age group between 21 and 25 years old endorsed the most psychiatric disorders, possibly stemming from ACEs. Our findings shed the light on the rising rate of psychiatric disorders in premenopausal women and support the growing public health burden of trauma exposure, particularly in childhood.

Introduction

Traumatic events such as interpersonal violence, discrimination and social exclusion can impact both the physical and mental health of an individual [1, 2]. In the United States, the lifetime prevalence of experiencing at least one traumatic event in adults is about 70% [3]. Particularly, women are exposed to higher rates of interpersonal trauma compared to men [4]. Several large-scale studies have examined the epidemiology of interpersonal trauma in psychiatric inpatient populations, providing valuable insights into gender differences in trauma exposure [5]. A population-based study in Ontario, Canada found that the gender gap in trauma exposure was also observed across different types of interpersonal trauma, including sexual, emotional and physical trauma [5]. Women’ unique social roles and responsibilities makes them more susceptible to certain types of trauma, such as sexual or physical assault. Unsurprisingly, childhood trauma is more common in women [6] and exposure to trauma during childhood may have a greater impact on women’ neurobiological development and mental health outcomes [7].

Individuals in urban setting, low-socioeconomic communities, particularly in minority groups are often exposed to a higher rate of traumatic events. For example, trauma exposure in urban African-American community ranges from 65 to 90%, with the prevalence of lifetime posttraumatic stress disorder (PTSD) exceeding the national average [8, 9]. The unique challenges and resource strain among groups from lower socio-economic conditions make them vulnerable to multiple episodes of trauma in their lifetime, increasing the risk of developing PTSD. Low-income urban populations face higher rates of interpersonal, sexual violence and adverse childhood events (ACEs) [10–12], which in part is responsible for the higher rates of PTSD, depression, and other mental health disorders in this population.

Our research study investigating autonomic and vascular consequences of PTSD in premenopausal women at the University of Minnesota generated a lot of interest in its first 2 years of enrollment in the Twin Cities area. This a 4-year NHLBI (K01HL161027) study aims to determine if trauma exposure and PTSD causes vascular, neural, and hormonal changes linked to an increased risk of hypertension and cardiovascular disease in premenopausal women, who are otherwise thought to be protected from cardiovascular disease due to the beneficial effect of estrogen. The current paper aims to provide an understanding of the prevalence of psychiatric disorders, types of traumas experienced, and behavioral risk factors associated with trauma exposure among the group of premenopausal women who completed the screening survey for our study during its first 2 years of enrollment (June 2022-July 2024). Additionally, we highlight the demographics of our participants (i.e. young trauma-exposed women in the Twin Cities of Minnesota). Finally, we explore if interpersonal trauma, particularly ACEs, would present with the highest rate of psychiatric disorders.

Methods

Ethical oversight and guidelines

This study was approved by the Institutional Review Board of the University of Minnesota. Informed consent was obtained from all participants, and all procedures and protocols performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. The parent study titled “Autonomic and Vascular Mechanisms of Cardiovascular Risk in Women with Post-traumatic Stress Disorder” is funded by an NIH K01 award (K01 HL161027) from the National Heart Lung Blood Institute (NHLBI). The study only enrolls premenopausal women to investigate the cardiovascular risk of trauma and PTSD in women before menopause.

Participants

Participants were recruited mainly through flyers. We posted our flyers around the University of Minnesota’s Twin-Cities campus and neighboring students’ housing, public libraries, coffee shops and women’s shelters. We also recruited using the University of Minnesota’s online research locator site called “StudyFinder”, a user-friendly tool designed to help potential participants find and connect with enrolling studies. In addition, we attended community health fairs and the Minnesota State fair to increase the awareness about mental health in young women and share information about our study to the broader community. Interested participants completed the screening survey using the QR code located on the flyers or contacted our laboratory using the phone number also provided on the flyer. The screening survey had questions such as “Have you ever been diagnosed with a mental health disorder” and if the participant responded yes to the question, they were prompted to list all psychiatric disorders they have been clinically diagnosed with. A total of 447 healthy young women between the ages of 18 and 40 years or of premenopausal status, with varying histories of trauma and mental illness diagnoses filled out the screening questionnaire using the University of Minnesota’s secure REDCap website (via the QR code). The data for this study was collected between June 2022 and July 2024.

Experimental design

Interested participants provided the following demographic information using the REDCap screening survey: age, menopausal status, height, weight, body mass index (BMI), health history such as any diagnosed cardiovascular, respiratory, and/or metabolic conditions, psychiatric disorder, contraceptives, and medication use. In addition, the participants provided habitual history such as alcohol consumption and tobacco use. Upon completion of the screening survey, the study coordinator contacted the participants to let them know if they were eligible for the study. Eligibility criteria for enrollment in the study included a history of trauma exposure, age (18–40 years) and/or premenopausal status, absence of pregnancy and/or breastfeeding, absence of any known cardiovascular disease, and the ability to give informed consent. Eligibility criteria were assessed via an online screening survey using the University of Minnesota’s REDCap server or phone interviews. Women were asked on the screening survey to list all current mental health disorders they have been clinically diagnosed.

Of the 447 women, 140 were eligible to enroll in the study. A detailed flow chart of participant enrollment is shown in Fig. 1. In this paper, we report data collected via our screening survey on REDCap and data collected in person via surveys. Eligible participants came in for an in-person visit at the University of Minnesota’s Minneapolis campus. During this visit, participants signed informed written consent and completed a race and ethnicity questionnaire. Next, we collected anthropometric data, which included height, weight, BMI, and abdominal circumference. Then, participants completed mental health and sleep questionnaires, after a thorough explanation of the aim of each questionnaire and detailed directions on how to complete them. They were given paper copies of the questionnaires to complete in a quiet area in the lab, starting with the sleep questionnaires and ending with the mental health questionnaires. Each questionnaire was explained to the participant by a trained study team member to ensure data completeness and accuracy. Participants were given the option to not share some details regarding their trauma history if they didn’t feel comfortable doing so. At the end of the visit, participants answered questions related to their menstrual cycle, contraceptive use, and breastfeeding status. We screened for pregnancy using a urine pregnancy test. Enrolled participants who completed the questionnaires were compensated $50 for this visit.

Fig. 1.

Flow chart showing detailed breakdown of participants screened for eligibility and total number enrolled for the study

Mental health questionnaires completed by enrolled participants

Of note, changes to the diagnostic criteria from the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) to the fifth edition (DSM-5) include the relocation of PTSD from the “anxiety disorders” category to a new diagnostic category named “Trauma and Stressor-related Disorders”.

PTSD checklist for DSM-5 with criterion A (PCL-5): To assess PTSD symptom severity and record the traumatic events reported by our participants, we used the PTSD checklist for DSM-5 with criterion-A (i.e. traumatic event). The PTSD checklist for DSM-5 (PCL5) is a 20- item self-reported questionnaire based on the DSM-5 symptoms of PTSD [13]. As part of this standardized measure, participants were asked in criterion A to “briefly identify their worst traumatic event (if they felt comfortable doing so)”. Enrolled participants have been categorized into two main categories based on the nature of the trauma (i.e. interpersonal and non-interpersonal). Interpersonal trauma being defined as the direct result of actions by others, such as abuse and neglect, and non-interpersonal trauma defined as other life-threatening events, such as accident, injury, illness, war, and natural disaster. Further, based on the response to criterion A of the PCL5, interpersonal trauma was subcategorized into- sexual abuse (i.e., rape, sexual assault), psychological/emotional abuse (i.e., parental neglect, emotional abuse from partner) and physical assault (i.e., assault and battery). Non-interpersonal subcategories are death of family/friend, accident, medical (i.e., trauma related to a medical procedure or hospitalization), violence (i.e., witnessing a violent event or a victim of violent crime), and natural disaster. In addition, the participants answered questions related to the timeline of the traumatic event, asking, “How long ago did it happen?” If the time frame given occurred during childhood, this was categorized as ACEs. Participants also answered how they experienced the event, if it happened to them directly or if they have witnessed it, and if the event involved the death of a close family or friend. Participants reported how much they were bothered over the past month by symptoms related to that traumatic event, using a five-point Likert scale (0 = “Not at all,” 1 = “A little bit,” 2 = “Moderately,” 3 = “Quite a bit,” 4 = “Extremely”). PCL-5 is a validated and reliable self-report measure of PTSD symptoms [14]. Additionally, PCL-5 have excellent psychometric properties with high interrater reliability, test–retest reliability, and internal consistency [15, 16]. The total score for PCL5 ranges from 0 to 80. A PCL5 cutoff score between 31 and 33 is indicative of probable PTSD, 33 and 45 is considered mild, a score > 45 and ≤ 60 is classified as moderate, and finally, a score > 60 is classified as severe PTSD [17].

Beck’s depression inventory (BDI): Beck’s depression inventory was used to assess participants’ depression symptoms. BDI-I is a well-validated 21-item self-report measure, scored from 0 to 3, of current depressive symptoms. In this study, items were summed to create an overall, continuous depression severity score and to compute a categorical diagnostic of current depression where a cutoff score greater than 18 suggested probable depression [18]. Overall, BDI is a psychometrically sound measure with good internal consistency, test–retest reliability [19].

Spielberger State-Trait Anxiety Inventory for Adults (STAI-A): To assess anxiety symptoms severity, we used the Spielberger State-Trait Anxiety Inventory for Adults. The state-trait anxiety inventory (STAI; “Form Y”) assesses self-reported anxiety (both state and trait anxiety) using a validated 40-item four-point Likert scale questionnaire [20]. State anxiety reflects transient (i.e., current moment) emotional anxiety due to situational stress. Trait anxiety assesses an individual’s predisposition to react with anxiety in any stressful event. Both subscales have been shown to have excellent internal consistency and test–retest reliability [21, 22]. STAI scores vary from a minimum score of 20 to a maximum score of 80 [20, 23].

Columbia Suicide Severity Rating Scale (C-SSRS): The Columbia Suicide Severity Rating Scale (C-SSRS) is a standardized assessment tool that uses questions to evaluate suicidal ideation and behavior in individuals. The C-SSRS consists of several sections, such as suicidal ideation, suicidal behavior, intensity of suicidal ideation or behavior, and lethality of suicidal behavior. Each section of the C-SSRS is scored based on the individual's responses with “yes” or “no”, “yes” indicating more severe suicidal ideation or behavior. Based on the participants’ responses, they were categorized as “no risk” if their response was no to a question related to any suicidal ideation, “low risk” if they responded yes to suicidal ideation but no to any suicidal behavior, “moderate risk” if they have suicidal behavior and “high risk” if they respond yes to the questions related intensity and lethality of suicidal behavior. C-SSRS is a well-validated scale with psychometrically sound and good convergent and divergent validity with other suicidal ideation and behavioral scales with high sensitivity and specificity [24].

The Pittsburgh Sleep Quality Index-Addendum for PTSD (PSQI-A): The Pittsburgh Sleep Quality Index-Addendum for PTSD (PSQI-A) is a self-report questionnaire comprising seven items designed to assess the frequency of nocturnal disruptive behaviors commonly associated with PTSD in adults [25]. PSQI-A has satisfactory internal consistence and acceptable convergent validity with PTSD severity, particularly focusing on disturbed nocturnal behaviors [25, 26]. This questionnaire uses a 0 to 3-point scale; respondents rate the frequency of seven disruptive behaviors over the past month. The cumulative scores, ranging from 0 (normal) to 21 (severe), a total score of ≥ 4 has been identified in the initial validation study as indicative of participants potentially experiencing PTSD-related disruptive nocturnal symptoms [25, 26].

Data analysis

Demographic characteristics and mental health diagnoses were assessed using the screening survey and expressed as percentages of the entire sample (n = 447). Participants were stratified by age and enrollment status. For analysis purposes, we divided participants into 6 age categories (18–20, 21–25, 26–30, 31–35, 36–40, and > 41 years old) to capture different stages of life in adulthood (i.e. early college years, first post-graduation employment, marriage, family).

Information on health and habitual history, as well as psychiatric disorders are reported by age category for the entire sample (i.e. recruited/screened, n = 447) and for the subset of enrolled participants (n = 140). Among enrolled participants, severity scores for PCL5, BDI, STAI, C-SSRS, and PSQI-A were stratified by age and also expressed as frequencies and percentages. Traumatic events reported were grouped in categories and sub-categories and expressed as percentages. All statistical analyses were done using SPSS software V29.0 (IBM, NY).

Results

Recruited/screened participants

Demographics: During the first year of our study, a total of 447 premenopausal women completed our screening survey via REDCap. The majority (~ 71%) of our participants were students (undergraduate and graduate) between the ages of 18–30 years old (Fig. 2). The mean age was 27 ± 7 years and the average body mass index (BMI) was 27.2 ± 6.7 kg/m².

Fig. 2.

Age distribution in our sample. The figure represents the age group distribution (%) of women interested in our study who filled out the REDCap survey (n = 447)

Health history: Participants' health history included history of respiratory disease such as asthma, heart disease, and medication for blood pressure (see Table 1). About 22% of our participants were on contraceptives, 21.7% were smokers, and 6.4% consumed alcohol regularly.

Table 1.

Health history and history of nicotine and alcohol by age category:

	Age categories (years)
	18–20	21–25	26–30	31–35	36–40	> 41
Health history
Heart problems (yes/no)	3/83	3/136	1/91	1/61	3/46	0/19
Respiratory problems (yes/no)	11/75	38/101	16/76	8/54	6/43	3/16
Birth control (yes/no)	19/67	44/95	22/70	10/52	5/44	1/18
Habitual history
Nicotine use (yes/no)	21/65	24/112	16/76	16/46	16/33	4/15
Alcohol intake (yes/no)	11/75	10/129	3/89	2/60	0/49	3/16

Mental health diagnosis: The most self-reported clinical mental health diagnosis in our sample was anxiety disorder (~ 53%), followed by depression (~ 46%) and PTSD (~ 35%). It is important to note that, as per DSM-5, we grouped under “anxiety disorder” self-reported diagnoses of generalized anxiety disorder, social anxiety, unspecified anxiety disorder and panic disorder. Further, 46% of participants reported more than one psychiatric disorder, specifically 37.8% reported at least a comorbid diagnosis of anxiety disorder and depression, 24.16% reported comorbid anxiety disorder and PTSD, and 22% comorbid PTSD and depression (Fig. 3). Figure 3 also highlights that 19% (n = 85) of women interested in our study endorsed all three psychiatric disorders, i.e.—depression, anxiety, and PTSD.

Fig. 3.

Percentages of reported mental health disorders in our sample (n = 447)

As seen in Fig. 4, the age group of 21–25 years appeared to endorse the most mental health diagnoses (23.3%, n = 104), followed by the age group of 26–30 years (16.6%, n = 74) and the age group of 18–20 years (13.9%, n = 62). Furthermore, women between the ages of 21–25 years presented with the most comorbid diagnosis of all three mental health diagnoses, followed by the age group of 26–30 years (Fig. 4).

Fig. 4.

Reported mental health disorders distribution by age group. The three most common mental health disorders by age group in our sample (n = 447)

Enrolled participants

Of the 447 participants, a subset of 140 who met the eligibility criteria were enrolled in our research study. The distribution of the enrolled participants’ age categories was consistent with that of the 140 participants. The majority of these enrolled participants were white, followed by African American, Hispanic and Asian (see Table 2). Similar to the overall group, enrolled participants between the ages of 21 and 25 years had the highest percentage of anxiety disorder (51.43% of all reported anxiety diagnoses, n = 72), PTSD (47.14% of all reported PTSD diagnoses, n = 66), and depression (45.0% of all reported depression diagnoses, n = 63).

Table 2.

Participants race (available for enrolled participants only, n = 136)

Race	N	%
White	87	63.97
African-American	25	18.38
Hispanic	8	5.88
Asian	10	7.35
Asian-Indian	3	2.21
Native American	3	2.21

Out of the 140 participants, 4 participants did not fill out a race and ethnicity questionnaire

Trauma exposure and sub-categories

Given that our study only recruited and enrolled women who have had a history of trauma exposure, all our enrolled participants reported at least one form of trauma. The PCL-5 survey with criterion A ask participants to briefly described their worst traumatic event. We categorize the traumatic events as interpersonal, non-interpersonal or mixed (i.e. both interpersonal and non-interpersonal) trauma based on the description provided. The most reported type of trauma was interpersonal trauma, followed by non-interpersonal trauma, and mixed (see Table 3).

Table 3.

Types of traumatic events reported with subcategories (available for enrolled participants only, n = 140)

Type of trauma	N	%
Category
Non-interpersonala	27	19.29
Interpersonalb	87	62.14
Mixedc	15	10.71
Adverse childhood eventd	66	47.14
Missinge	11	7.86
Sub-category
Sexual abuse	49	35.00
Psychological/Emotional	32	22.86
Physical	16	11.43
Accident	15	10.71
Death of family or friend	12	8.57
Medical	9	6.43
Violence	6	4.29
Natural disaster	2	1.43

^aNon-interpersonal trauma is a form of trauma that does not result from interaction between people

^bInterpersonal trauma is psychological trauma as a result of interactions between two or more people

^cMixed type of trauma when participants reported both interpersonal and non-interpersonal trauma

^dAmong participants who reported interpersonal and mixed trauma, a subset of those were subcategorized as adverse childhood events based on the timeline of the trauma

^eNine missing data since participants did not report any trauma history in the PCL5. Of note, some of our participants endorsed two or more subcategories of trauma

Of note, among the women who reported at least one form of interpersonal trauma, we found that 75.9% were ACEs (66 out of 87). Eleven women chose not to describe or specify their trauma. However, they answered questions regarding trauma symptoms severity.

Interpersonal trauma subcategories: 35.0% of our enrolled participants reported sexual abuse, 22.9% reported psychological/emotional trauma, and 11.0% reported physical abuse.

Among the women with adverse childhood events, ~ 56% (n = 37) reported a diagnostic of anxiety disorder, ~ 54% (n = 36) PTSD and ~ 42% (n = 28) depression. Of note, 27% of these women reported being clinically diagnosed with all three psychiatric disorders, while 39% reported co-morbid anxiety disorder and depression, 37% co-morbid PTSD and anxiety disorder, and 29% co-morbid PTSD and depression.

Non-interpersonal trauma subcategories: 11.4% of our enrolled participants reported accidents, 8.6% reported death of family or friends, and 6.4% reported medical trauma (Table 3).

Other mental health surveys

PTSD (PCL-5): 38.8% of our enrolled participants reported subthreshold PTSD symptoms severity and 23.7% moderate PTSD symptoms severity (Table 4). One participant had missing data. Additionally, our enrolled participants also filled out surveys assessing depression symptoms severity (BDI), anxiety symptoms severity (STAI), suicide (C-SSRS), and sleep disturbances (PSQI-A).

Table 4.

Mental health and sleep surveys symptoms severity scores (available for enrolled participants only)

Mental health surveys	Categories	N	%
PCL-5	Subthreshold PTSD	54	38.85
	Probable PTSD	9	6.47
	Mild	29	20.86
	Moderate	33	23.74
	Severe	14	10.07
	Total	139
BDI	Normal	34	24.46
	Mild mood disturbances	38	27.34
	Borderline clinical depression	17	12.23
	Moderate depression	28	20.14
	Severe depression	16	11.51
	Extreme depression	6	4.32
	Total	139
STAI-Trait	No or low anxiety symptoms	54	39.13
	Moderate anxiety symptoms	24	17.39
	High anxiety symptoms	60	43.48
	Total	138
STAI-State	No or low anxiety symptoms	25	18.12
	Moderate anxiety symptoms	21	15.22
	High anxiety symptoms	92	66.67
	Total	138
C-SSRS	No Risk	70	51.47
	Low Risk	21	15.44
	Moderate Risk	39	28.68
	High Risk	6	4.41
	Total	136
PSQI-A	No sleep disturbance	34	25.37
	Sleep disturbance	100	74.63
	Total	134

PCL-5 = PTSD checklist for DSM-5 with criterion A; BDI = Beck’s Depression Inventory; STAI = State-Trait Inventory for Adults; C-SSRS = Columbia Suicide Severity Rating Scale; PSQIA = PTSD Addendum for Pittsburgh Sleep Quality Index

Depression (BDI): The majority of our enrolled participants reported mild to no depression (see Table 4), followed by moderate depression. We had one missing data.

Anxiety (STAI): Overall, enrolled women had high trait (see Table 4) and state anxiety symptoms severity. Two participants had missing data.

Suicidal Behavior (C-SSRS): The majority of the enrolled participants had no risk of suicide, followed by moderate risk (see Table 4). Four participants chose not to complete the C-SSRS.

Sleep (PSQI-A): One hundred women (74.6%) reported having sleep disturbance. There were 6 missing data (Table 4).

Discussion

This manuscript examined the demographics, history of trauma exposure and psychiatric disorders endorsed by a diverse group of premenopausal women who completed the screening survey for our NIH K01 research study in the Twin-Cities area. We report that our participants often endorsed more than one psychiatric disorder diagnosis, with varied trauma histories. We found that those with a history of ACEs had the highest rate of psychiatric disorders, namely PTSD and anxiety disorder.

All participants in the study were trauma-exposed due to the enrollment criteria, and the majority of enrolled participants endorsed more than one type of trauma. Our participants reported higher rates of anxiety disorder, depression, and PTSD diagnoses. The most common psychiatric disorder reported in our sample was anxiety disorder, followed by depression, both at a higher rate than the national average [27, 28]. Further, we recorded higher rates of PTSD and anxiety disorder in women who experienced ACEs, sexual trauma and intimate partner violence. Notably, one-third of these women endorsed all three psychiatric disorders reported in this study (i.e., anxiety, depression, and PTSD). Conversely, we found fewer reports of PTSD or depression diagnosis in women with non-interpersonal trauma such as illness, medical procedure, or accident. Our observations are consistent with findings from Breslau et al. (1998), which suggest that interpersonal trauma poses a higher risk for the development of psychopathology compared to non-interpersonal trauma [9, 29]. Furthermore, prior reports support an elevated risk of PTSD in individuals with ACEs following subsequent traumatic events, and this is in line with our findings [30]. We also noticed a comparable rate of anxiety diagnosis in our subset of women with ACEs. It is important to note that although PTSD was recategorized as a Trauma and Stressor-Related Disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD is still considered an anxiety disorder by some clinicians as per DSM-IV and bears similarities when it comes to diagnosis, treatment and comorbidities.

The majority of our participants were between the ages of 18–30 years old, and this age group is uniquely susceptible to trauma exposure due to significant life transitions such as driving independently, leaving home, starting college, graduating, entering the workforce, and forming new relationships [31, 32]. These life events/milestones often place young women in new environments and social contexts that may expose them to traumatic experiences such as assault, accidents, or disasters. An epidemiological study conducted in the UK reported that the median age of first trauma exposure is 15 years, with a lifetime trauma exposure prevalence of 31.1% by the age of 18 [32]. Due to the cross-sectional nature of the study, we were not able to capture the year-by-year incidence of trauma exposure. However, we were able to note the high rate of ACEs in our sample because 76% of interpersonal trauma reported by our participants occurred in childhood.

Individuals with psychiatric disorders often present with comorbid behavioral risk factors associated with trauma exposure, such as obesity, alcohol, nicotine usage and suicidal tendencies [33]. Similarly, our participants were overweight, suggesting maladaptive behaviors promoting high cardiometabolic risk in these participants. Prior research suggests a strong association between trauma exposure, particularly in early life, and higher adult BMI [34, 35]. Further, individuals with PTSD also show higher rates of obesity and faster weight gain over time, indicating a well-described comorbidity [36–38]. The overall trend in BMI could be suggestive of the presence of possible eating disorders and sedentary lifestyles in these young trauma-exposed women. Additionally, self-reported sleep disturbances, a hallmark of trauma exposure and PTSD, were common among our participants. Sleep deprivation can potentially contribute to increases in caloric intake and obesity [39]. Other risk behaviors such as alcohol intake were reported in our sample, although one-third of participants reported using nicotine. Individuals with psychiatric disorders often report frequent use of nicotine, at higher rate than the general population, possibly as a maladaptive coping strategy or shared genetic pathways [40, 41].

The current study has several limitations- first, we used a cross-sectional retrospective approach to assess these demographics. Second, we relied on participants’ reported diagnoses of PTSD, depression and anxiety. Thus, there is a potential impact of self-reported bias on our results, which can limit generalizability of the findings. However, after enrollment in the study, we assessed symptoms severity using well-validated questionnaires (i.e. PCL5, STAI, BDI). Third, we did not record race and ethnicity data for all screened participants. Race and ethnic background can be an important factor in trauma exposure, making racial/ ethnic minorities more susceptible to various types of trauma exposure due to socioeconomic disparities that places them in unsafe environments and at-risk conditions (including medical). A national epidemiological survey in the United States using data from 34,653 individuals found that PTSD is highest among African American and lowest among Asians [42]. However, we have the race and ethnicity data of the subset of enrolled participants which was predominantly White Caucasians. We are currently implementing new recruitment strategies to increase the diversity of our sample. Fourth, socioeconomic condition was not captured in the present study, which clearly influences trauma exposure [43]. The next step is to investigate if premenopausal women with interpersonal trauma and/or ACEs present with more severe psychiatric disorders compared to matched controls exposed to non-interpersonal trauma. We are not currently powered to test that hypothesis because of the smaller number of women reporting non-interpersonal trauma.

The findings of this study suggest that the age group between 21 and 25 years endorses the most mental health diagnosis and risk behaviors associated with trauma. A population-based study in Ontario, Canada found that a gender gap in the lifetime prevalence of traumatic experiences was observed across different types of interpersonal trauma, including sexual (22.7% in women vs. 8.4% in men), emotional (33.3% vs. 19.4%), and physical trauma (24.2% vs. 14.8%) [5]. Our current findings shed the light on the rising rates of trauma exposure in young women and support the growing public health burden of trauma exposure, particularly at a young age. Therefore, we think that future research should focus on how to mitigate the physiological impact of trauma in young women prior to the development of overt co-morbidities such as cardiovascular and metabolic diseases. By implementing early intervention strategies and thereby preventing psychiatric disorders such as anxiety disorder, depression and PTSD to become chronic and/or severe, we could mitigate the cost associated with the treatment and rehabilitation of co-morbidities. On a separate note, data from this sample was previously published [44, 45]. In the first manuscript, we reported that PTSD symptom severity was associated with reduced microvascular endothelial function; and in the second manuscript, we found that premenopausal women with PTSD had higher pulse wave velocity and blunted vagal control of the heart [44, 45]. These prior findings support a link between PTSD and early markers of cardiovascular disease risk in otherwise healthy premenopausal women, thereby adding to the public health burden of psychiatric disorders.

Authors contributions

I.F. was responsible for the study conception and design, data collection, analysis and interpretation of results, and manuscript preparation; C.T.T. was responsible for data collection, analysis and interpretation of results, and manuscript preparation; Z.A. and A.M. were responsible for data collection, analysis and interpretation of results; C.I.T, R.W., and C.C. were responsible for data collection. All authors read and approved the final manuscript.

Funding

This study was supported by the following Grants: K01HL161027 (NHLBI), and UMN CTSI UL1TR002494.

Data availability

Data for this study will be available upon request.

Declarations

Competing interests

The authors declare no competing interests.