stress, early trauma, ptsd and the effect on hiv...• argento, et al. (2017) violence, trauma, and...
TRANSCRIPT
Stress,EarlyTrauma,PTSDandtheEffectonHIV
SusanneAstrabFogger,DNP,PMHNP-BC,CARN-AP,FAANP
AssociateProfessor
Conflictofinterest• Thespeakerhasnoconflictofinteresttodeclare
Objectives• Nameoneaspectofhowadversechildhoodeventseffectadultsyearslater
• IdentifytwophysicalissuesrelatedtochronicstressandPTSDandHIV
• Listtwomanagementstrategiestodecreasechronicstress
TreatingpeoplewithHIV
• Requiresmorethanjusttreatingthevirus• Understandingtheroleoftraumainkeepingpeoplesick• Canhelpteamssupporttheperson’smovementtoward
optimumhealth
Stressanddistress…Whatisthedifference??• Normallifestress- psychologicalandphysicalreactiontoapositiveornegativesituationlikeanewjoborsignificantloss
• Eustress- positivestress-motivates,&focusesenergy,feelsexciting&improvesperformance
• Negativestress– Distress- causesanxiety,perceivedasoutsideourcopingability,feelsunpleasant&decreasesperformance
Selye StressAdaptationModel(1956)• Threestages• Alarm–“fightorflight”• Increasedalertness,mobilizeresources& defenses• Releaseofnorepinephrine& epinephrine• Vasoconstriction,increasedBP,increasedHR& cardiaccontraction
• Ifstressorcontinues&isnotadaptivelyoreffectivelyresolved,……
Selye -- StressAdaptationModel• Resistance• Optimaladaptationtostresswithintheperson’scapabilities• Hormonesreadjust,reductioninactivityandsizeoftheadrenalcortex
• Increased& intensifieduseofcopingmechanisms• Relyondefenseorientedbehavior,psychosomaticsymptoms•
• StageIII- Exhaustion• Lossofabilitytoresiststressduetodepletionofbodyresources
• Decreasedimmuneresponse• suppressionofTcellsandatrophyofthymus• depletionoftheadrenalglands&hormoneproduction
• Personbecomedisorganize/realitymaybeimpaired
Anxietyrelatedresponsecriticalforsurvival• Increasednoradrenergicanddopaminergicsystemactivation
(leadingtocentralnervoussystemhyperarousal&hypervigilance)facilitatesrapidreaction
• Theeffectivenessoftheresponsefades ifcontinuouslyexposedtostressor.
• Decreaseineffectiveness• relatedtothealterationincatecholamine& thyroidsystems• depressedimmunesystem.
Longtermstressors
• Individualincreasinglysensitivetosubsequentstressorswhichmoreeasilyreactivatetheanxietyrelatedresponse
PTSDriskfactors• Experiencingintenseorlonglastingtrauma• Experiencingothertraumaearlierinlife• Abusedorneglectedaschild
• Adversechildhoodevent(ACE)
• HavingotherMHproblemsincludinganxietyordepression• Lackinggoodsupportsystemoffamilyorfriends• Beingfemale• HavingafirstdegreerelativewithMHproblems
Adversechildhoodexperiences(ACE)• Includespsychological,physical,sexualformsofabuse• householddysfunction:substanceuse,mentalillness,violence& incarceration
• Doseresponseof4ormoreACE• IncreaseinHIVriskybehaviors
AdverseChildhoodExperience11itemsurvey• 1.Livedwithanyonewhowasdepressed,mentallyillorsuicidal• 2.Livedwithanyonewhowasaproblemdrinkeroralcoholic• 3.Livedwithanyonewhousedillegaldrugsorabusedprescription
drugs• 4.Livedwithanyonewhoservedtimeinacorrectionalfacility• 5.Experiencedparentalseparationordivorce• 6.Witnessedparentoradultinthehomeslap,hit,kick,punchor
beateachother
• 7.Beingslapped,hit,kicked,punchedorbeatbyparentsoradultsinthehome
• 8.Beingsworeat,insultedorputdownbyparentsoradultsinthehome
• 9.Beingtouchedsexuallybyadultoranyoneatleast5yearsolderthanrespondent
• 10.Beingmadetotouchsexuallyanadultoranyatleast5yearsolderthantherespondent
• 11.Beingforcedtohavesexwithanadultoranyoneatleast5yearsolderthantherespondent
PhysicalEffectofhighlevelsofviolence/trauma• Bluntedheartratevariabilityinresponsetostressisanindicatorofautonomicdysfunction-
• whenstressed- HRincreasedby17BPMlessthanchildrenmatchedtotheiragewhohadnotbeenexposedtoviolence• cardiovascularriskfactor
• ChildrenexposedtohighlevelsofurbanviolencedemonstrateacceleratedcellularagingmeasuredbyDNAmethylation• predictsallcausemortalityrisklaterinlife
Noradrenergichyperactivity
• Excessivenoradrenergicoutputfromthelocusceruleus– autonomicoverdrive• Centralsymptomsofanxiety&fear• Nightmares,hyper-arousalstates• Flashbacksandpanicattacks• Excessivenoradrenergicactivitycanalsoreducethe
efficiencyofinformationprocessingintheprefrontalcortex
Riskybehavior--increasesrisk- Sexworkers• CrystalmethamphetamineInjection(CM)• Womenuseatthesamerateasmen• >61%reportedsexualphysicalabusebeforeage18• AmongthosewhoInjectedCM75%experiencedabuse• OftheCMinjectionusers25%hadHIV• Amongsexworkers,CM- directeffectonsexualdesire,alsoimpaired
judgmentandincreasedlikelihoodofunprotectedsexandsyringesharingheighteningtheriskofHIV.
• Argento,etal.(2017)Violence,Trauma,andliningwithHIV:Longitudinalpredictorsofinitiatingcrystalmethamphetamineinjection amongsexworkers.DrugandAlcoholDependence.175,198-204.
Women,HIVandhistoryoftrauma• 30%ofHIVpositivewomenhadPTSD• 5X>nationalsampleofwomen
• 55%ofHIVpositivewomenhaveexperiencedintimatepartnerviolence– 2Xnationalrate
• Womenaccountfor27%ofallnewHIV/AIDSdx• AfricanAmerican&Hispanicwomenrepresent77%
Childhoodsexualabuse(CSA)
• Riskfactorfornegativementalandphysicalhealthoutcomesinadults
• Linkedtodepression,substanceuseandPTSD• Amongmen-having-sex-with-men(MSM)• CSAashighas35.5%• Comparedtogeneralpop.Estimatesof13.5%ofwomen
• 2.5%ofmen
Untreateddepression• Reductioninadherence• Complicationspreventeffectivetreatment• Hopeless• Moreimpulsive• Carelessaboutownsafety• Increasesdiseaseprogression
Strategies• Visualization,guidedimagery& meditation• Relaxationtraining• Decreaseunhealthy&selfdestructivebehaviors• Engaginginhobbies• Spendingtimewithcaring,supportive& optimisticpeople• Engageinpersonalgrowthactivities
BreathingBasedMeditation• Mindfulnesspracticecanhelpaddressdissociativesymptomsasthepersonfocusesoninnerself
• Trainingalsofacilitatesneurologicalchangesresponsiblefortheregulationofemotion& positivelycorrelatestoanxietysymptomimprovement
• Consistentmindfulnessdecreasesamygdalareactivity• fostersgreaterfunctionalconnectivitybetweenamygdala• &prefrontalcortexregions
• Breathingexercises• activatesbothsympathetic¶sympatheticsystems
• Elucidatingbothalertness&calm• Increasedoptimism& generalwellbeing
Grouptherapy–SupportandCBTfocused• “Notalone”• Altruism• Socialconnections• Cognitivebehavioralfocus- interruptingmaladaptivethinking• Preventionfocus• Healthylifestyle
Commoncopingtechniques• Problemssolving• Assertivenessskillbuilding• Positiveselftalk• StressandAngerManagement• Skillsneededforcommunicationandrelationships
Meication• Medications• SSRIs– paroxetine,venlafaxine,fluoxetine&sertraline• Significantlymoreeffectivethanplacebo• Maytakeupto6weekstoreachtherapeuticbloodlevel• Sideeffects– wt gain,sexualsideeffects&stigma• Pharmacologicalinterventionscanbeeffective
• About40%withPTSDnolongermeetcriteriaforPTSD
TaiChi
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••
AncientChinesemedicine/martialarts• Mind-bodyconcept• Humanbodyhasenergychannels–
•
Yoga• Yogabasedinterventions• Decreaseautonomicnervoussystemactivation• Decreasesbloodpressureandheartrate• Participantsexperienceasenseofrelaxation• PostyogaimprovesGABAlevels• DecreasePTSDhyper-arousalsystem• Promotespsychologicalflexibilityandemotionalregulation
Yoga• Elucidatingbothalertnessandcalm• Increasedoptimismandgeneralwellbeing
SummaryAdjunctivetherapiessuchasyoga,Taichiandbreathingbasedmeditationhaveagrowingevidencebase
Senseofimprovedsymptommanagement,purposeandinternallocusofcontrol
Offeringindividualizedpatientcenteredcareincludesnon-pharmacologicaltreatmenttoaugmenttraditionaltherapy
Recommendations:• GiventhebehavioralconsequencesofnottreatingPTSD:• Screeningforrecentandpasttrauma,PTSD• ScreeningshouldbepartofthecorecomponentsofHIV
treatment• Interventionstoincreaseresiliencethroughself-efficacy• Increasingaccesstointegrated,traumainformedmentalhealth,
addictiontreatmentandHIVcare
Suggestedreading:
• TheBodykeepstheScoreBrain,MindandBodyintheHealingofTrauma• BesselVanDerKolk MD
References
• Brown,M.J.,Masho,S.W.,Perera,R.A.etal.(2017).SexDisparitiesinAdverseChildhoodExperiencesandHIV/STIs:MediationofPsychopathologyandSexualBehaviors.AIDSBehav .21:1550.doi:10.1007/s10461-016-1553-0
• Cambell,J.,Walker,R.,&Egedes,L.(2016).Associationbetweenadversechildhoodexperiences,Highriskbehaviors,andmorbidityinadulthood.AmericanJournalofPreventionMedicine. 50(3),344-352.
• Kemppainen,J.,MacKain,S.,Alexander,M.,ReidP.,&JacksonM.(2017).PosttraumaticstressdisorderandstressfullifeeventsamongruralwomenwithHIVdisease.JournaloftheAssociationofNursesinAIDSCare.28(2),216-225.
• Machtinger,E.,Wilson,T.,Haberery,J.,&Weiss,D.(2012).PsychologicaltraumaandPTSDinHIVpositivewomen,ameta-analysis.AIDSBehavior.16:2091-2100.