TFG - Vucic Sanchez, Ana Maria

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FACULTAD DE CIENCIAS HUMANAS Y

SOCIALES

The relationship between physical and mental health,


and the effect of early trauma and discrimination.

Autor/a: Ana María Vucic Sánchez


Director/a: Ignacio Echegoyen Blanco

Madrid
2022/2023
Table of contents

1. Introduction ........................................................................................................ 2
2. Methods............................................................................................................... 4
3. Results ................................................................................................................. 5
3.1 Physical Health Effects on Mental Health .................................................................5
3.2 Mental Health Effects on Physical Health .................................................................8
3.3 Effects of Trauma and Adverse Childhood Experiences on Health ......................... 11
3.4 Social Factors Influencing Health and ACEs .......................................................... 13
4. Conclusions ........................................................................................................18
5. Discussion ..........................................................................................................19
References..............................................................................................................22

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1. Introduction

John Steinbeck (1962) once said that “a sad soul can kill you quicker, far quicker,
than a germ.” While it may be true that we have advanced substantially in the field of
mental health, and that we take better care of that sad soul now than we did in the first
half of the twentieth century, there is still much disregard around this topic in the medical
field. Today in age, we tend to refer to the soul as the mind, but it gets sad just the same.
There is a tendency to shy away from the complex origins that cause us to be sad and the
many mental illnesses with which we cohabitate. Moreover, there is much neglect around
the tight-knit relationship that poor mental states have with all the germs, or physical
illnesses, we are more accustomed to treating.

The concept of health is a complex one that, due to its intangible nature, can be
difficult to define. According to the Constitution of the World Health Organization
(2002), “Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.” This definition marks how simply the absence
of illness, will not ensure well-being. A term that could be described in simple terms as
“judging life positively and feeling good” (Center for Disease and Control [CDC], 2018).
By these modern theories of what constitutes health and well-being, it is evident that the
concept of health has developed to be viewed in a more holistic fashion, and addressed in
a way that better aligns with the biopsychosocial model.

This model, originally proposed by George Engel in 1977, refers to


“methodological assumptions that causes and/or cures of specific conditions at specific
stages, including matters of adjustment and quality of life, will generally – across a wide
range of conditions – include biological, psychological and social factors, and interactions
between them” (Bolton, 2022). It is very important that we understand our health as
multifactorial. By continuing to explore these factors in an integrated fashion we should
aim to avoid interpreting them as being independent of one another. Comprehending the
complex relationships between our biological, psychological, and social factors, and how
they interact with each other, will be paramount to treating and preventing all sorts of
diseases that make our lives more difficult.

For example, we know today that poor mental health puts people at risk of having
more problems with their physical health. Particularly with cardiometabolic diseases,
there is a 1.4 to 2 fold increased chance for people with mental illness to suffer from

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diabetes, obesity, and cardiovascular disease (Firth et al., 2019). This relationship is a
two-way street. While mental illness can contribute to the development of chronic
disease, these chronic diseases can also have effects on the emotional state of patients and
be a factor in the development of mental health disorders: there are indications that there
is a bi-directional relationship between the two (Chen et al., 2016).

This phenomenon could be one of the factors playing a part in the shortened
lifespan of those with severe mental illness (SMI). This category refers to people suffering
from diseases like major depressive disorder, schizophrenia, and bipolar disorder. People
with SMI have a reduced life expectancy of 10-15 years compared to people who are not
mentally-ill (Melamed et al., 2020). To better prevent these serious and persistent
illnesses, comprehending their etiology is fundamental.

In analyzing mental and physical health, each day we are learning to better
appreciate how our early experiences will later take a toll on both. The original Adverse
Child Experiences (ACE) Study (Felitti et al., 1998) had a groundbreaking impact on the
understanding of risk factors for disease and physical and mental health. There are three
types of ACEs: abuse, neglect, and household dysfunction. The first includes physical,
emotional, and sexual abuse. The second includes physical and emotional neglect.
Finally, under household dysfunction we find mental illness, incarcerated relative, mother
treated violently, substance abuse, and divorce. There are other factors that have not
received as much attention but are starting to be addressed as ACEs as well: peer violence
(bullying), sibling violence, and witnesses interpersonal violence (Hughes et al., 2017, as
cited in Riedl et al., 2020).

This study showed the medical field just how important our early childhood
experiences are, particularly traumatic ones. People who have been exposed to abuse
and/or household dysfunction as children have a higher chance of suffering from disease
in adulthood. For example, there’s an increased risk for those who have faced four or
more ACEs to develop cancer, heart disease, and diabetes (Boullier & Blair, 2018).

ACEs can happen in any household, although there are certain risk factors that
increase their likelihood. Children who live in poverty, are black, and have special health
care needs, are more likely to experience ACEs (Crouch et al., 2019), and with these
identities comes the hard reality of a discriminatory society. Discrimination and ACEs
unfortunately work very well together. People tend to suffer more from psychological

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distress when they are affected by ACEs and discrimination, compared to those who have
not experienced discrimination and have little or no ACEs. ACEs can also amplify how
discrimination correlates with anxiety and depression (Helminen et al., 2022).

Moreover, these traumatic experiences have a significant impact on the mental


health of these individuals in their adult lives, such as mental illness and health risk
behaviors. These health risk behaviors can also give us clues to better understand what
intermediary elements can play a role in the physical health problems to which this
population is more vulnerable. There is a graded relationship between having experienced
different categories of ACEs and health risk behaviors (Felitti et al., 1998). These include
alcoholism, drug abuse, smoking, physical inactivity, severe obesity, 50 or more sexual
partners, depression, and suicide attempts.

Outside of specific circumstances that can be categorized as ACEs, poverty levels


and discrimination can also be directly linked to the topic of mental health. A study in
Australia found that there is a bidirectional relationship between affordable housing
outcomes and mental health and physical health (Baker et al., 2013).

This integrative review aims to demonstrate the relationship between traumatic


experiences and effects on physical and mental health, while pointing out the ways in
which mental and physical health may feed into one another. It is important to also shine
light on the context of people’s struggles with trauma and disease to be able to paint the
whole picture. This study will address the ways in which poverty, discrimination, and
violence can exacerbate these symptoms and create more obstacles and boundaries for
these communities to be able to experience well-being and improve their economic and
social resources. Specific factors will be explored such as wealth, race, sexuality, and
gender.

2. Methods

Various databases were used to compile data from a multitude of studies related
to the central and minor topics discussed. These included PsycInfo, Psicodoc, and
Psychology and Behavioral Science Collection. Key terms and keywords that guided the
research were: physical health or physical wellbeing or physical illness or physical health
problems, mental health or mental illness or mental disorder or psychiatric illness, adverse
childhood experiences, severe mental illness, long term conditions or chronic disease or

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chronic conditions or chronic illness, long term effects or long term complication or long
term impacts, stress and anxiety, common mental disease or depression or anxiety,
psychosomatic or psychosomatic symptoms, effects, stress, stress and health, police or
policing, community violence or neighborhood violence, discrimination or prejudice or
stereotype or bias or stigma, minority stress, racial discrimination, allostatic load,
minority stress theory, pharmacological treatment or pharmacological intervention or
pharmacological therapy, HPA axis or hypothalamic-pituitary-adrenal axis,
psychoimmunology, health outcomes or health consequences or health, and health effects
or health impact or health risk. The information was organized and presented to meet the
objectives of the study.

3. Results

3.1 Physical Health Effects on Mental Health

Results. There are specific diseases and conditions which have received more
attention regarding their relationship with mental health. The following section will
address the effects that physical diseases can have on a person’s mental health.

Cancer. There has been extensive research on the mental health of cancer patients,
in the field known as psycho-oncology. Many patients with cancer who were
psychologically healthy prior to their diagnosis experience emotional distress and even
psychiatric diagnoses after starting this process (Roy, 2022). Approximately 30-60% of
cancer patients have a psychological disorder and between 29-43% meet the criteria of a
psychiatric diagnosis (Anuk et al., 2019). One study that specifically centered on tobacco-
related cancers found that 73% of patients have common mental disorders (Barbhuiya,
2020).

This data is alarming, especially given the likelihood of underreporting. It is


estimated that less than 10% of cancer patients are referred to mental health professionals
to receive help. Of those that are referred to psycho-oncological help, 97.5% receive a
psychological diagnosis (Anuk et al., 2019). This data puts into question how the numbers
would look if all cancer patients had access to some sort of mental health evaluation and
assistance. It is evident that the stressor of a disease such as cancer will cause
psychological distress in patients.

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Chronic diseases. People with a chronic condition have to live with the negative
physical symptoms of the disease for all, or almost all of their life. Along with these
hardships, many also suffer from comorbid mental health conditions (Duong &
Bradshaw, 2016). In some cases, this can contribute to people thinking about taking their
own life. There is a relationship between chronic physical conditions and suicide ideation
that can be linked directly or through the mediator of mental disorders such as post-
traumatic stress disorder (PTSD) and depression (Vasiliadis et al., 2021).

We can see the effects on youth who at a young age are already diagnosed with a
chronic disease. In an extensive study of U.S. youth suffering from chronic physical
conditions, the adjusted risk of comorbidity with chronic mental health conditions was
51% greater than those without (Adams et al., 2019). At the age of 10, children already
present disproportional rates of mental illness, which continue to be reaffirmed at 13 and
15 years of age (Brady et al., 2020). This is a problem that starts early on and, with the
life-long nature of these conditions, will likely persist in these patients’ lives.

Infectious diseases. The effects of infectious diseases on people’s mental health


have been appreciated for a significant time now. In the early 20th century, scientists were
linking infectious diseases like typhoid fever, pneumonia, mumps, scarlet fever, and
influenza to the apparition of psychotic, manic, and depressive episodes. The recent
Covid-19 pandemic also offered evidence of people being left with long-term
neuropsychiatric symptoms due to damage from the virus’ ability to infect the brain
(Perozzo et al., 2021). This showed a direct link between the disease and its ability to
affect the mental health of the person, but we also see an indirect psychological distress
linked to the intense fear of infection, social isolation, and economic stress that most
people were subject to.

This indirect relationship to a deteriorated mental health is common among


infectious diseases, as is the case with Tuberculosis (TB). Despite the alarming death toll
and prevalence of TB worldwide, there is very limited data on its relationship to mental
health. In a hospital in Nigeria, significant differences were observed when comparing
the rates of psychiatric disorders in people with pulmonary TB and patients with bone
fractures. While 5% of the health control group presented psychiatric disorders, the
numbers rose to 15% in the orthopedic group, and 30.2% in the TB group (Aghanwa &
Erhabor, 1998). Another more recent qualitative study in Russia examined how TB was
affecting infected adolescents. They expressed fear and anxiety over their health outcome,

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a more negative evaluation of themselves, strongly linked to feelings of shame and a
diminished social network due to rejection by their peers (Zvonareva et al., 2021).

HIV is another infectious disease that, despite the incredible advances in its
prevention and treatment, continues to affect many people’s lives in very significant
ways. The relationship between HIV and psychiatric disorders seems to be bidirectional,
and very much affected by stigma and discrimination (Cohen et al., 2021). Screening for
the psychiatric morbidity of HIV positive people in Kenya, 71.4% of the patients at the
clinic had mental health disorders. Among these, 32.2% had major depressive disorder,
18.4% had PTSD, 17.6% had dysthymia, 17.6% had obsessive-compulsive disorder,
16.3% had low-risk suicidality, and 11.4% had mania (Ng’ang’a et al., 2018). Other
investigations in Sub-Saharan Africa, the region of the world with the greatest number of
people living with HIV, have continued to register the high frequency of stigma and
common mental illness, especially depression, in this population (MacLean & Wetherall,
2021; Motumma et al., 2019).

While there are always intermediary mechanisms facilitating the deterioration of


a person’s mental health when they are living with a physical illness, with infectious
diseases there seems to be more awareness of what those elements might be.

Causal mechanisms and moderator variables. Convalescent individuals


experience stigma that is extremely harmful, and this is one of the explanations for the
deterioration of the mental health of physically ill people. In the case of TB, HIV, and
epilepsy, the stigma these patients live with is associated with mental health disorders,
especially anxiety and depression (Kane et al., 2019). Later on, we will discuss the role
of discrimination and stigma on a person’s health more in depth.

The limiting effects that many physical diseases have on the body can lead to
physical inactivity and sedentarism—other important factors that facilitate the
relationship with poor mental health outcomes. We know that exercise has direct benefits
for preventing or minimizing mental illnesses like depression or depressive symptoms
(Kohut, 2019), and for many ill people exercise is very difficult or simply not a reality.
For chronic disease, in the study mentioned earlier by Adams et al. (2019), 13.5% of the
relationship was found to be mediated by activity limitations. Additionally, metacognitive
beliefs are associated with depression and anxiety among a vast number of physical
illnesses (Capobianco et al., 2020). Household income has been identified as a moderator

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between chronic health conditions and SMI (Duong & Bradshaw, 2016), a topic that will
also be discussed further on.

Organismal homeostasis, and especially central nervous system homeostasis, can


be influenced by many factors including genetics, physiology, psychological wellbeing,
and lifestyle circumstances. Disruption of these factors, combined with activation of
immunological/inflammatory responses, can contribute to the development of
neuropsychiatric disorders (Perozzo et al, 2021). While the activation of
immunological/inflammatory responses can be beneficial in fighting detrimental
infections, long-term or exaggerated inflammatory responses can lead to a continued
elevation of inflammatory cytokines, chemokines, and neurotransmitters. This has led to
the definition of the “cytokine hypothesis of depression,” where neuromodulators and
other proinflammatory cytokines are essential components of the neuroendocrine,
neurochemical, and behavioral features of depressive disorders (Schiepers et al, 2005).
Also, it was reported that several inflammatory diseases (e.g., rheumatoid arthritis) are
associated with depression, and that inflammatory cytokines can promote depressive
symptoms and hyperactivity in the hypothalamic-pituitary-adrenal (HPA) axis (Schiepers
et al, 2005; Flux & Lowry, 2023). Commensal gut bacteria can also regulate production
of inflammatory cytokines and consequently influence inflammatory processes in the gut
and the whole body (Flux & Lowry, 2023). Furthermore, the neuro-immune affective
framework that targets regions of the prefrontal cortex and emotion regulation is affected
by the endocrine and immune systems (Lopez et al, 2018). Together, all these studies
indicate that the immune system plays an important role in the function of neuronal
circuits and therefore also in psychological health.

3.2 Mental Health Effects on Physical Health

Results. Mental health conditions have effects on the body and our physical health
as well. When looking at 16 mental illnesses, most had a link to 10 subsequent chronic
physical diseases that was statistically significant. These relationships ranged between
having an odds ratio1 (OR) of 1.2 and 3.6 (Scott et al., 2016). Along with reviewing
evidence for these relationships, it is important to understand what mechanisms might be
acting as intermediary factors in creating these effects.

1 Odds ratio (OR) is a measure of the frequency of occurrence of an outcome relative to the frequency of
it not occurring (George et al., 2020).

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Severe mental illness. The strain that different mental illnesses can exert on a
person’s health can vary. SMI can take a particularly heavy toll. One study on cancer
survival outcomes comparing patients with and without psychiatric disorders found
significant differences for those diagnosed with depression (hazard ratio2 [HR] = 1.16)
schizophrenia (HR = 1.62), or bipolar disorder (HR = 1.35). In contrast, patients
diagnosed with anxiety did not have significant differences (HR = 1.07) in their cancer
survival outcome when compared to the control group (Benny et al., 2022). These
findings are further confirmed by significantly lower survival rates of women with breast
cancer who have SMI, particularly non-affective psychosis (Ahlgrén-Rimpiläinen et al.,
2020).

We also see these detrimental effects in other physical conditions. People with
schizophrenia are more likely to suffer from physical illnesses and have a significantly
reduced life expectancy that is 10-25 years lower than the rest of the population (Crump
et al., 2013). The cause is currently unknown, but this increased risk is not due to genetic
liability as some had considered (Kendall et al., 2020). This information leaves a lot of
questions around what stressors schizophrenia and other SMI have on the body and why
they have such substantial impacts on the person’s physical health.

Personality disorders. There are ten different personality disorders (PD). Each is
characterized by its own particular set of traits and behaviors that constitute a very well-
established pattern that dictates how the individual acts in most or all environments. These
disorders are marked by how the way they live their life and interact with others deviates
from what is culturally expected or acceptable. Their maladaptive patterns of behavior
are affected in at least two of the following: cognition, affectivity, impulse control, and
interpersonal functioning.

There are clear indications that there is a link between PD and having physical
health problems (Dixon-Gordon et al., 2018; Dokucu & Cloninger, 2019). Any severe PD
will be associated with more physical, mental, and social disorders. Poor health was
reported by more individuals with PD (41.3%) than those without PD (15%), along with
a greater percentage of people having more than three illnesses, both when excluding
depression (19.9% vs 8.9%) and including depression (22.9% vs 9.9%) (Fok et al., 2014).

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The hazard ratio (HR) measures the different rates at which an event occurs in two groups that differ in
a relevant factor (George et al., 2020).

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The physical illnesses that are more prevalent in people with PD include asthma, other
respiratory problems, arthritis/rheumatism, back problems, and migraines. PD are also
associated with chronic disease, obesity, sleep disturbances, and pain conditions (Dixon-
Gordon et al., 2018).

Stress. Stress tends to come up more often as an intermediary factor between


psychosocial adversities and the final consequences that show up as physical and mental
symptoms. Therefore, aside from this section, we will explore stress further when we
discuss the effects of social factors and discrimination on people’s health.

Stress has been demonstrated to influence the onset and maintenance of several
physical and psychiatric conditions (Slavich & Auerbach, 2018). Somatic conditions
include diabetes, asthma, chronic pain, arthritis, metabolic syndrome, inflammatory
bowel syndrome, and cardiovascular disease. For example, with diabetes, stress affects
the glycemic control (HbAlc) and mortality of those patients. For people who are diabetic,
stress related to their work (β = 0.65, 95%) and to their perception of how stress may
affect their physical health (β = 0.60, 95%) increases HbAlc levels (Walker et al., 2019).
In the case of asthma, we can also identify an increased health risk. The accumulation of
stress on adolescents will decrease their asthmatic control, decrease their perceived
quality of life, and increase their visits to the emergency room (Miadich et al., 2020).

In older populations, stress can particularly affect the self-perception of health.


Days with higher self-perceived stress are correlated with worse self-perceived health and
self-perceived aging (Whitehead & Blaxton, 2020). There are many factors that can affect
stress levels. Material hardship is one of the many variables that will increase perceived
levels of stress, and in turn this stress can be linked to more mental and physical health
problems (Woo et al., 2021). Due to the importance of the stressors themselves, it is
important we analyze all of their impacts on our health.

Causal mechanisms and moderator variables. Many patients with mental


illness are prescribed psychiatric medication that can have secondary negative effects on
patients’ physical health such as weight gain, total cholesterol, fasting glucose, and
HbA1c levels (Croatto et al., 2022). Life stress can modify the regulation of the
hypothalamic-pituitary-adrenal (HPA) axis, which is associated with poor physical and
mental health outcomes (Young et al., 2021).

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The lifestyle that is often observed in people with depression and SMI, specifically
related to inactivity and diet, can predispose people to developing diabetes or worsen the
progression of the condition (Holt, 2019). Variables mediating the relationship between
PD and poor health include concurrent mental illnesses like depression, lack of adherence
to the treatment of chronic illnesses, emotional dysregulation, higher rates of
polypharmacy that has its own set of health risks, biological vulnerabilities like metabolic
syndrome or BMI, deteriorated relationships with their healthcare services, and
personality factors that influence their perception of health (Dixon-Gordon et al., 2018;
Fok et al., 2014).

3.3 Effects of Trauma and Adverse Childhood Experiences on Health

Results. When addressing trauma, we will tend to focus on ACEs due to the
extensive research around this topic. Because of the attention this criterion has received
globally, we must also note the cultural differences that may play into their varied
frequencies. A metanalysis conducted in 2017 by Hughes et al., in an attempt to bring
together the results of many studies conducted worldwide, was confronted with the fact
that there was some variety within the factors that were being analyzed as ACEs.
Depending on the study, they found that between 12-67% of people have experienced no
ACEs, whereas 1-38% of participants have a prevalence of four or more ACEs.

A common feature in all these studies was the way they correlated with health
problems and health risk behaviors. Persons with four or more ACEs had a four times
higher chance of having mental distress or a mental disorder. Among physical illnesses,
respiratory diseases had the most significant correlation to having experienced four or
more ACEs with an OR of 3.05. The other diseases that were reviewed were liver and
digestive disease with an OR of 3.05, cancer with an OR of 2.31, cardiovascular disease
with an OR of 2.07, and diabetes with an OR of 1.52. Even stronger than these
relationships were those linked to health risk behaviors such as heavy alcohol use (OR =
2.20), smoking (OR = 2.82), having multiple sexual partners (OR = 3.64), early sexual
initiation (OR = 3.72), teenage pregnancy (OR = 4.20), illicit drug use (OR = 5.62),
problematic alcohol use (OR = 5.84), sexually transmitted infections (OR = 5.92),
violence victimization (OR = 7.51), violence perpetration (OR = 8.10), problematic drug
use (OR = 10.22), and finally, suicide attempt (OR = 30.14). These health risk behaviors

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can give us a lot of information around possible mediators between the adverse
experiences from a person’s childhood and their health outcomes in their adult life.

These results have been confirmed in later studies, as is the case with a study done
specifically with hospital patients. They found a positive correlation between having
experienced more ACEs and a higher number of physical disorders (r = 0.16, p < .001),
depression (r = 0.32, p < .001), anxiety (r = 0.30, p < .001), somatization (r = 0.18, p <
.001) and experiences of domestic violence (r = 0.42, p < .001). Polyvictimized patients,
those who had experienced four or more ACEs, again saw the most drastic increase
compared to those without ACEs. The odds ratios within physical disorders: chronic pain
(OR = 3.8), urogenital disorders (OR = 2.8), gastrointestinal and musculoskeletal
disorders (both OR = 2.30). Among mental health disorders, polyvictimized patients had
an 8.9 times higher chance of having depression and 6.4 times higher odds of having
anxiety. These patients also were 10.4 times more likely to have experienced domestic
violence in their adult lives (Riedl et al., 2020).

While this study focused predominantly on the negative effects of poor health in
one personal area on another, we can appreciate that the opposite could also be true.
Though ACEs increase the chance of having anxiety or depression in adolescents,
positive childhood experiences can moderate the impact of those ACEs on their mental
health (Qu et al., 2022).

Expanding the lens to trauma in general, not just adverse situations before the age
of 18, the effect on the person’s health is maintained. A traumatic event is when someone
personally experiences or is witness to the threat of a person’s life or integrity. People
who have experienced trauma are more likely to have problems with their cardiovascular,
reproductive, gastrointestinal, brain, immunological, muscoloskeletal, and
neuroendocrine health. The symptoms they experience also make them more vulnerable
to developing other medical conditions (Kumari & Mukhopadhyay, 2020).

Causal mechanisms and moderator variables. As with stress, trauma also has
an important effect on the HPA axis by chronically activating it, along with the
sympathetic nervous system. This has significant implications like increasing allostatic
load and altering the natural levels of cortisol and norepinephrine (Kumari &
Mukhopadhyay, 2020). The idea of allostatic load is used to explain how even small
changes may combine to negatively impact health. Biological, psychological, behavioral,

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and attentional changes associated with PTSD are the proposed mechanisms through
which it may affect physical health (Schnurr, 2022). Early life stresses transform into
biological signals that are concurrently or successively incorporated into the
cardiovascular and metabolic systems, along with the brain (Mariani et al., 2021). This
biological embedding also causes changes in the immune, endocrine, and nervous
systems, affecting in turn the allostatic load as well.

The moment in which an individual experiences a traumatic event might be


important. Studies have indicated the possibility of there being particularly sensitive
periods in a child’s brain development, that can be associated with psychological
disorders like major depression, though it is too early in the findings to draw final
conclusions (Riedl et al., 2020). Others have identified the role of executive functions as
mediating factors between ACEs and mental health outcomes and health-risk behaviors
(Danese & McEwen, 2012)

Emotional intelligence was found to play an intermediary role between child


maltreatment and posterior depression and anxiety (Zhao et al., 2020). Bullying
victimization can be very traumatic for children, and the quality of the relationship that
the child has with their father was found to mediate the psychosomatic symptoms they
could potentially develop (Hong et al., 2021). In line with a previous topic, mental health
disorders influence the association between childhood trauma and chronic physical
disorders (Noteboom et al., 2021). With such a circular concept, these different variables
can sometimes, act as cause, effect, or pathways between other variables.

3.4 Social Factors Influencing Health and ACEs

Results. In contrast to a more medical approach, the biopsychosocial model also


aims to attend the more social, societal, or external factors affecting an individual. These
stressors can include economic pressures like poverty, social pressures like
discrimination, violent environments, and many more.

Socioeconomic conditions. The socioeconomic realities of families will have an


important effect on their health risks and outcomes. Financial hardship significantly
increases the chance that someone has experienced an ACE in their life. It has been
demonstrated that 47% of children in households living above the poverty line have not
experienced any ACEs. That number drops for children who come from households
below the poverty line, where 12% have not been exposed to any ACEs. As a whole, there

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was also a link between more exposure to ACEs and worse access to public
transportation, housing, and breastfeeding counselling (Blair et al., 2019).

Financial debt is one of the forms that will take a monumental toll on a person’s
health. When explored, people who have debt have a significantly worse self-rated health,
higher levels of perceived stress, along with more depressive symptoms and anxiety
(Sweet, 2020). Most of these individuals had to pass on medical care or skip housing bills
at some point due to their financial debt.

Looking at hospital workers specifically, a profession whose wages many times


do not reflect the importance of their job, material hardship was clearly correlated to
worse mental health. But there were additional variables that were found to have
significant relationships that widen our scope on this issue. These included hourly pay,
education, ethnicity or race, and age with mental health, perceived stress, and food
insecurity (Woo et al., 2021).

Poverty or income levels may also be seen as a moderator between different health
outcomes, such as between chronic diseases and probable SMI, indicating that these
relationships become significant or exponentiated in the presence of financial insecurity.
In the case of asthma, only low-income households are significantly correlated to
probable SMI. Whereas for diabetes, middle-income households have a significant
relationship with probable SMI (Duong & Bradshaw, 2016). Economic hardship is a
stressor in and of itself that affects peoples’ health, but it can also add additional pressure
to other existing relationships, like the ones we have previously discussed.

Discrimination. The impact of the treatment, acceptance, and integration we


receive by our communities can extend further than we may expect. When these aspects
are absent or done so negatively, we find situations of discrimination that can
consequently be associated with a deteriorated physical and mental health (Leger et al.,
2022). Over extended periods of time, the significant relationship between lifetime
discrimination with negative health outcomes is very apparent.

There are many personal characteristics for establishing discrimination. One of


those forms is ageism, which on a yearly basis accounts for 17.04 million cases of the
eight most expensive health conditions (Levy et al., 2020). People who have been victims
of child trafficking also face discrimination that negatively affects their physical and
mental health outcomes. Due to the stigmatization that this group faces, they receive more

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barriers to health care and are not properly attended, leaving them with significant
differences in their health quality compared to the rest of the population (Wallace et al.,
2022). These are two examples of discrimination that people face, but the majority of
studies focus on other very common forms of discrimination like racism, xenophobia,
homophobia, and transphobia.

People who are gender and sexual minorities are at risk of experiencing negative
health outcomes such as immune dysregulation, problems sleeping, and psychological
distress that are due to the stress caused by personal and structural discrimination and
stigma (Christian et al., 2021). Together with the minority stress and discrimination, there
is a constant need for physical vigilance because of the safety threats. This has detrimental
long-term effects on peoples’ psychological, emotional, and immunological health
(Diamond & Alley, 2022). A study in Chile focused on transgender people describes how
discrimination and stigma affect their mental health, leading to problems with their self-
image, anxious and depressive symptoms, alcohol and other substance abuse, suicidal
ideation or suicide attempts, and self-harm (Delgado et al., 2019). Even within the
overarching trans community, stress affects nonbinary people differently due to the
binary structures of our society and culture (Matsuno et al., 2022), though this
population’s experience has yet to be further studied.

The treatment that people face for being immigrants in a country will also have a
detrimental impact on their health. Aside from xenophobia, a migratory process entails
many more hardships such as isolation, stigma, racism, instability, being separated from
family, fear of deportation, and a lack of resources. Disparities in mental health among
Latinx immigrants can be linked to the stressful and inequitable contexts of discrimination
and historical loss (Handal et al., 2022). Focusing on immigrant Mexican women, it is
clear that through discrimination, they are more likely to experience acculturative stress,
psychological distress, depressive and anxious symptoms, and role limitation (Mendoza
Griego, 2022). These effects on the mental health of immigrants have also been quantified
in the United Kingdom following Brexit. The areas inhabited by more “leave” voters
correlated with higher rates of discrimination, which was associated with increased
symptoms of generalized anxiety disorder (Frost, 2020). So much so, that it increased the
chance of having clinically significant symptoms (OR = 3.01). This study illustrates the
importance of how structural stigma has an important impact on the mental health of
marginalized communities.

15
Much xenophobic discrimination is closely intertwined with racist attitudes,
which also pose threats to peoples’ health. The strongest evidence in this field of research
indicates a significant impact of racial discrimination on a person’s mental health and
psychological well-being, along with health risk behaviors such as eating patterns, trouble
sleeping, and consuming substances such as alcohol, drugs, and tobacco. Data also points
to a relationship between racism and hormonal dysregulation, inflammatory markers, and
allostatic load (Bailey et al., 2017). The medical attention people receive can be impacted
by discrimination. As such, there are significant disparities in women’s health according
to race and ethnicity, with growing evidence pointing to discrimination as an underlying
cause (Akinade et al., 2022). For African Americans, racism plays a role in the
documented health disparities, such as a lower life expectancy and higher risk of mortality
from Covid-19, as the CDC identified (Reid & Earnshaw, 2022). Racism is associated
with increased anxiety symptoms and poor sleep for Black adults, both with personal
experiences of everyday racism and vicarious experiences of major discrimination
(Manning et al., 2022; Moody et al., 2022). Other ethnic minorities report parallel
experiences with the effects on their mental health, such as with Chinese American
university students where stress related stressors and racial discrimination are positively
associated with anxiety symptoms (Haft et al., 2022).

Many people are subject to these and many other forms of discrimination. The
risk of death increases with the number of stigmatized social identities that a person
identifies with or belongs to (Manning et al., 2022). The ways in which communities treat
their members personally and structurally has very significant impacts on their quality of
life and health.

Police and community violence. The CDC considers the misuse of force by law
enforcement a public health issue due to the magnitude of deaths and injury that the police
is responsible for in the United States (CDC, 2010, as cited in Adekale, 2021). The actual
physical injury from excessive force, or when police kill civilians, represents the direct
detrimental effects that law enforcement’s misuse of violence has on health. However,
negative effects can also be caused indirectly. These indirect effects tend to be more
visible on peoples’ mental health, and one study found a multitude of specific examples.
People who have experienced a police intrusion are more likely to be experiencing PTSD
symptoms, and the intensity of the symptoms increases with the aggressivity of that
intrusion. For Black adults there is a relationship with psychosis when having been

16
exposed to police abuse, and anxiety is significantly related to the frequency and
intrusiveness of police stops among men. There can also be strong effects from witnessing
police violence, not only experiencing it firsthand. People who have experienced or
witnessed law enforcement abuse report negative effects on their mental and
physiological health. The news can also take a significant toll because the way in which
media covers these topics can provoke pain, stress, and diminished feelings of self-worth
for community members (Simckes et al., 2021).

As seen with other types of external pressures, the perception of police misuse of
force is related to higher levels of stress in the community. Certain subgroups are more
vulnerable to this stress like Black people, women, and people who are unemployed. On
the other hand, it is important to note the positive implications that more community
cohesion and feelings of safety in the neighborhood can have, as it is associated with
better health for its members and lower levels of stress (Stansfield, 2022).

This concept of feeling safe in one’s community is important because it can have
serious implications for a person’s health. Neighborhood violence is associated with
negative health outcomes (Semenza & Stansfield, 2021). One specific example would be
for asthma. High crime in a community has been identified as a trigger for toxic stress
that increases the amount of asthma diagnoses in youth (Merrill et al., 2021). The violence
that people are exposed to on a more systemic level, like their community and the state,
greatly affects their health outcomes.

Causal mechanisms and moderator variables. Many of the moderating factors


discussed in the previous section on trauma and ACEs could be applied to situations of
exclusion, discrimination, and violence, as these experiences can be very traumatic for
those who live them. For example, interpersonal racism has been associated with
allostatic load, hormonal dysregulation, and inflammatory markers, all biomarkers of
wellbeing and disease (Bailey et al., 2017). In the case of policing, epigenetic changes
such as the functioning of the HPA axis, our stress response system, might be partially
responsible for deteriorated health, and allostatic load has been identified as a significant
contributor to the elevated mortality levels among Black adults (Simckes et al., 2021).
Stress is a key moderating factor for health outcomes, particularly in the case of
discrimination and wage insecurity (Christian et al., 2021; Frost, 2020; Leger et al., 2022;
Woo et al., 2021). It is referred to as minority stress, and throughout this paper we have
discussed the effects that stress will have on our health and wellbeing.

17
The autonomic nervous system (ANS) might play a significant role as well. In the
case of the Chines American college students, respiratory sinus arrhythmia reactivity, the
measure they used to represent the reactivity of the ANS, moderated the association
between discrimination and anxiety symptoms (Haft et al., 2022). Other factors are quite
dependent on or linked to the environment and resources of a person.

Transportation is a key factor in the relationship between poverty and ACE


incidence. In the case of “3 or more ACEs,” 21% of the income-based inequality could
be eliminated if everyone had access to transportation (Blair et al., 2019). In the case of
asthma, geographic location is very important because inequalities in health outcomes
and life opportunities are perpetuated by neighborhoods as a mechanism for
environmental injustice (Harris, 2019). However, for discrimination, lifetime or prior
usage of mental health resources moderated or eliminated its relationship with anxiety
symptoms (Manning et al., 2022; Moody et al., 2022). And as discussed earlier,
discrimination within healthcare services themselves are an underlying cause that
explains health disparities (Akinade et al., 2022; Wallace et al., 2022).

4. Conclusions

It is increasingly evident that multiple aspects of any person’s circumstances and


environment need to be properly understood, addressed, and cared for in order to ensure
the individual’s health. Our physical health strongly affects our state of mind, and our
mental health has important effects on our body as well. Adversities, violence, and
stressors that people are exposed to on a personal, community, and systemic level will all
affect our physical and mental health. Even when certain external variables are primarily
associated with the body or the mind, we know that body and mind are profoundly
interconnected by a two-way street with heavy flowing traffic. When one falls ill, the
chances increase that the other will do so as well. It is impossible and counterproductive
to view our health as any less than a complete and integrated picture of our physical,
mental, and social components. It is important that we continue to research all of these
relationships and their effects to strengthen the ways in which we attend to the patients in
our offices and care for the people in our world.

18
5. Discussion

The principal complication that I struggled with while investigating this topic
illustrates the exact barrier that I aim to shine a light on with this paper. It is impossible
to separate the specific variables discussed, as I have attempted to do, while researching
and presenting the relevant data that I have found. The reason that the writing is structured
by different subsections is to facilitate the information to the readers. Without headings
for concrete directional impacts, along with their pertinent scientific exploration and
findings, the investigation ran the risk of being a very long and confusing list of how
absolutely everything impacts everything else.

Though that format would have been difficult to read, it may have been more true
to the dilemma that is being studied. It is clear that with health, humans cannot separate
their physical health from their mental health and their social health. All of these variables
will have an impact on one another, which is made evident by just trying to research the
individual relationships. I found that when trying to focus on a specific heading, it was
impossible to type keywords into the search engine and find articles focused exclusively
on that one subtopic. For example, with the question on how stress impacts physical
health, I found thousands of research leads that could be grouped into almost all of the
major headings. This is because stress impacts physical health, but a chronic physical or
mental illness might also cause someone to experience stress. Furthermore, a lot of stress
is informed by difficult social circumstances like poverty, but stress might impact how
well someone does their job and working poorly could cause them to lose their job
(causing more stress), etc. These loops could come up endlessly for all of the different
dimensions, and though their circularity might pose extra difficulties for research, it only
points to how important it is to continue exploring. We might not be able to uncover a
magical solution that solves all of the mysteries behind these intricate processes, but we
can always improve the current understanding that we have.

There are few notable limitations in this paper. First, due to length constraints, it
lacks a section addressing how negative health outcomes could impact a person’s
economic and social status within a society. To attempt to complete the full picture, it
would be helpful to discuss how disease or illness might affect the access to job
opportunities, and the possibility of structural discrimination. Second, because of how
complex the topic of health is, there are many physical diseases, mental illnesses, and

19
social factors that were not addressed, and there are a lot more moderating factors that
connect all of these variables. Third, ideally, the way the information was presented could
always be improved in order to better reflect the circularity between variables that was
aimed at being demonstrated. But due to the complexity if these bidirectional and circular
relationships, I aired on the side of clarity in fear of how chaotic the other structure would
have been to read and understand.

A limitation that confronts the entire field of health, is the dualistic tendency to
separate a person into physical health, mental or emotional health, and social health. The
research focuses on how one variable affects one other variable, when it is impossible to
ignore that these three (very general and overarching) variables are always acting at all
times, and not only that, but they are influencing each other. We cannot completely block
the confounding effects that make up (arguably) a third of that person we are studying.
We must continue to strive for research that is truly integrative on a biological,
psychological, and social level. That would allow us to better understand ourselves and
better treat ourselves, to know towards what type of health infrastructure we need to
move. Right now, our doctor’s office, therapist clinic, social services, and community
centers tend to be isolated players working individually, when human health is a team
sport. While there is communication between these parties, they frequently only start
working together when the patients’ discomfort or situation reaches quite drastic points.
We should strive to improve this communication and promote the custom of
interdisciplinary teams with holistic interventions.

The relationship between the health of our mind and that of our body can be traced
back to when we were small children, vulnerable to the many adversities our
environments can offer. Unmet physical needs and abuse, along with verbal and
emotional ones, leave scars, pain, and trauma. These factors can lead to emotional and
behavioral patterns that surface in the form of disease and, possibly, premature death. All
this can lead to an endless cycle that, unless we intervene with prevention and treatment,
will continue to undermine the lives of so many throughout the globe. In this regard, early
intervention as a means of prevention is also incredibly important. A child that
experiences ACEs will most likely experience better health outcomes if they have access
to health professionals such as psychologists and social workers that can help the child
process the trauma, and support their environment and the adults in their life with tools
and education. Extensive longitudinal studies focusing on ACEs, social and economic

20
adversities, and health outcomes over the course of peoples’ lives could give invaluable
information for getting a full understanding of what people need, especially if we focus
on the protective variables and those that promote health.

Because people that have suffered from ACEs tend to be impoverished and form
part of marginalized groups, it is important to improve the resources and conditions to
help these populations. In so doing, we will reduce the self-supporting cycles that lead to
the maintenance of mental and associated physical diseases, and in consequence reduce
not only the ongoing suffering of the afflicted, but also diminish the toll on the health of
the overall society to which these people belong. It would also be quite informative to
study how the relationship between ACEs or social adversities changes in different
countries or states, depending on whether there is access or not to public healthcare,
including mental health services.

The research and attention paid to this topic is beyond significant. It has direct
effects on our population’s health and well-being, and has the potential to decrease the
existing disparities that establish abysmal differences in regard to the guarantees for
health and happiness of a person according to their living conditions.

21
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