Stress, Early Trauma, PTSD and the Effect on HIV...• Argento, et al. (2017) Violence, Trauma, and...
Transcript of Stress, Early Trauma, PTSD and the Effect on HIV...• Argento, et al. (2017) Violence, Trauma, and...
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–
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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.