Childhood trauma and systemic lupus erythematosus activity in Tunisian patients: exploring the mediating role of post-traumatic stress disorder.

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease influenced by multiple factors. Growing evidence suggests that adverse childhood experiences (ACEs) and post-traumatic stress disorder (PTSD) may contribute to immune dysregulation and increased disease activity. However, these associations remain poorly explored in North Africa and the Middle East. OBJECTIVE: This study aimed to investigate the mediating role of PTSD in the path from ACEs to SLE activity. METHODS: This cross-sectional study involved adult patients with SLE treated at the Internal Medicine Department of Mahdia University Hospital between September 2024 and February 2025. We used the validated Arabic version of the WHO Adverse Childhood Experiences International Questionnaire, the Arabic PTSD Checklist for DSM-5. Disease activity was assessed using medical record-derived Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and British Isles Lupus Assessment Group scores. Statistical analyses included χ2 tests and Student's t-tests for group comparisons, Pearson correlation analyses and mediation analysis using the Sobel test. RESULTS: This study included 106 Tunisian adults with SLE, predominantly women (88.7%), with a mean age of 48.6 ± 12.8 years. All participants reported at least one ACE, with intra-familial adversities being highly prevalent (96.2%). Extra-familial ACEs were reported by 67% of patients, most commonly community violence (43.4%). Probable PTSD was present in 57.5% of participants. Exposure to community violence (43.4%) was significantly associated with higher disease activity (SLEDAI and BILAG), p<0.001). Patients meeting criteria for probable PTSD also exhibited higher disease activity (SLEDAI: p < 0.001; BILAG: p = 0.044). Mediation analysis showed that PTSD partially mediated the association between childhood community violence and SLE activity, accounting for 27.7% of the total effect on SLEDAI and 41.5% on BILAG. CONCLUSION: PTSD appears to play a key mediating role, highlighting the need for trauma-informed and interdisciplinary approaches in SLE management.