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...
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Stress,EarlyTrauma,PTSDandtheEffectonHIV
SusanneAstrabFogger,DNP,PMHNP-BC,CARN-AP,FAANP
AssociateProfessor
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Conflictofinterest• Thespeakerhasnoconflictofinteresttodeclare
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Objectives• Nameoneaspectofhowadversechildhoodeventseffectadultsyearslater
• IdentifytwophysicalissuesrelatedtochronicstressandPTSDandHIV
• Listtwomanagementstrategiestodecreasechronicstress
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TreatingpeoplewithHIV
• Requiresmorethanjusttreatingthevirus• Understandingtheroleoftraumainkeepingpeoplesick• Canhelpteamssupporttheperson’smovementtoward
optimumhealth
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Stressanddistress…Whatisthedifference??• Normallifestress- psychologicalandphysicalreactiontoapositiveornegativesituationlikeanewjoborsignificantloss
• Eustress- positivestress-motivates,&focusesenergy,feelsexciting&improvesperformance
• Negativestress– Distress- causesanxiety,perceivedasoutsideourcopingability,feelsunpleasant&decreasesperformance
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Selye StressAdaptationModel(1956)• Threestages• Alarm–“fightorflight”• Increasedalertness,mobilizeresources& defenses• Releaseofnorepinephrine& epinephrine• Vasoconstriction,increasedBP,increasedHR& cardiaccontraction
• Ifstressorcontinues&isnotadaptivelyoreffectivelyresolved,……
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Selye -- StressAdaptationModel• Resistance• Optimaladaptationtostresswithintheperson’scapabilities• Hormonesreadjust,reductioninactivityandsizeoftheadrenalcortex
• Increased& intensifieduseofcopingmechanisms• Relyondefenseorientedbehavior,psychosomaticsymptoms•
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• StageIII- Exhaustion• Lossofabilitytoresiststressduetodepletionofbodyresources
• Decreasedimmuneresponse• suppressionofTcellsandatrophyofthymus• depletionoftheadrenalglands&hormoneproduction
• Personbecomedisorganize/realitymaybeimpaired
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Anxietyrelatedresponsecriticalforsurvival• Increasednoradrenergicanddopaminergicsystemactivation
(leadingtocentralnervoussystemhyperarousal&hypervigilance)facilitatesrapidreaction
• Theeffectivenessoftheresponsefades ifcontinuouslyexposedtostressor.
• Decreaseineffectiveness• relatedtothealterationincatecholamine& thyroidsystems• depressedimmunesystem.
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Longtermstressors
• Individualincreasinglysensitivetosubsequentstressorswhichmoreeasilyreactivatetheanxietyrelatedresponse
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PTSDriskfactors• Experiencingintenseorlonglastingtrauma• Experiencingothertraumaearlierinlife• Abusedorneglectedaschild
• Adversechildhoodevent(ACE)
• HavingotherMHproblemsincludinganxietyordepression• Lackinggoodsupportsystemoffamilyorfriends• Beingfemale• HavingafirstdegreerelativewithMHproblems
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Adversechildhoodexperiences(ACE)• Includespsychological,physical,sexualformsofabuse• householddysfunction:substanceuse,mentalillness,violence& incarceration
• Doseresponseof4ormoreACE• IncreaseinHIVriskybehaviors
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AdverseChildhoodExperience11itemsurvey• 1.Livedwithanyonewhowasdepressed,mentallyillorsuicidal• 2.Livedwithanyonewhowasaproblemdrinkeroralcoholic• 3.Livedwithanyonewhousedillegaldrugsorabusedprescription
drugs• 4.Livedwithanyonewhoservedtimeinacorrectionalfacility• 5.Experiencedparentalseparationordivorce• 6.Witnessedparentoradultinthehomeslap,hit,kick,punchor
beateachother
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• 7.Beingslapped,hit,kicked,punchedorbeatbyparentsoradultsinthehome
• 8.Beingsworeat,insultedorputdownbyparentsoradultsinthehome
• 9.Beingtouchedsexuallybyadultoranyoneatleast5yearsolderthanrespondent
• 10.Beingmadetotouchsexuallyanadultoranyatleast5yearsolderthantherespondent
• 11.Beingforcedtohavesexwithanadultoranyoneatleast5yearsolderthantherespondent
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PhysicalEffectofhighlevelsofviolence/trauma• Bluntedheartratevariabilityinresponsetostressisanindicatorofautonomicdysfunction-
• whenstressed- HRincreasedby17BPMlessthanchildrenmatchedtotheiragewhohadnotbeenexposedtoviolence• cardiovascularriskfactor
• ChildrenexposedtohighlevelsofurbanviolencedemonstrateacceleratedcellularagingmeasuredbyDNAmethylation• predictsallcausemortalityrisklaterinlife
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Noradrenergichyperactivity
• Excessivenoradrenergicoutputfromthelocusceruleus– autonomicoverdrive• Centralsymptomsofanxiety&fear• Nightmares,hyper-arousalstates• Flashbacksandpanicattacks• Excessivenoradrenergicactivitycanalsoreducethe
efficiencyofinformationprocessingintheprefrontalcortex
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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.
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Women,HIVandhistoryoftrauma• 30%ofHIVpositivewomenhadPTSD• 5X>nationalsampleofwomen
• 55%ofHIVpositivewomenhaveexperiencedintimatepartnerviolence– 2Xnationalrate
• Womenaccountfor27%ofallnewHIV/AIDSdx• AfricanAmerican&Hispanicwomenrepresent77%
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Childhoodsexualabuse(CSA)
• Riskfactorfornegativementalandphysicalhealthoutcomesinadults
• Linkedtodepression,substanceuseandPTSD• Amongmen-having-sex-with-men(MSM)• CSAashighas35.5%• Comparedtogeneralpop.Estimatesof13.5%ofwomen
• 2.5%ofmen
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Untreateddepression• Reductioninadherence• Complicationspreventeffectivetreatment• Hopeless• Moreimpulsive• Carelessaboutownsafety• Increasesdiseaseprogression
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Strategies• Visualization,guidedimagery& meditation• Relaxationtraining• Decreaseunhealthy&selfdestructivebehaviors• Engaginginhobbies• Spendingtimewithcaring,supportive& optimisticpeople• Engageinpersonalgrowthactivities
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BreathingBasedMeditation• Mindfulnesspracticecanhelpaddressdissociativesymptomsasthepersonfocusesoninnerself
• Trainingalsofacilitatesneurologicalchangesresponsiblefortheregulationofemotion& positivelycorrelatestoanxietysymptomimprovement
• Consistentmindfulnessdecreasesamygdalareactivity• fostersgreaterfunctionalconnectivitybetweenamygdala• &prefrontalcortexregions
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• Breathingexercises• activatesbothsympathetic¶sympatheticsystems
• Elucidatingbothalertness&calm• Increasedoptimism& generalwellbeing
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Grouptherapy–SupportandCBTfocused• “Notalone”• Altruism• Socialconnections• Cognitivebehavioralfocus- interruptingmaladaptivethinking• Preventionfocus• Healthylifestyle
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Commoncopingtechniques• Problemssolving• Assertivenessskillbuilding• Positiveselftalk• StressandAngerManagement• Skillsneededforcommunicationandrelationships
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Meication• Medications• SSRIs– paroxetine,venlafaxine,fluoxetine&sertraline• Significantlymoreeffectivethanplacebo• Maytakeupto6weekstoreachtherapeuticbloodlevel• Sideeffects– wt gain,sexualsideeffects&stigma• Pharmacologicalinterventionscanbeeffective
• About40%withPTSDnolongermeetcriteriaforPTSD
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TaiChi
•
••
AncientChinesemedicine/martialarts• Mind-bodyconcept• Humanbodyhasenergychannels–
•
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Yoga• Yogabasedinterventions• Decreaseautonomicnervoussystemactivation• Decreasesbloodpressureandheartrate• Participantsexperienceasenseofrelaxation• PostyogaimprovesGABAlevels• DecreasePTSDhyper-arousalsystem• Promotespsychologicalflexibilityandemotionalregulation
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Yoga• Elucidatingbothalertnessandcalm• Increasedoptimismandgeneralwellbeing
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SummaryAdjunctivetherapiessuchasyoga,Taichiandbreathingbasedmeditationhaveagrowingevidencebase
Senseofimprovedsymptommanagement,purposeandinternallocusofcontrol
Offeringindividualizedpatientcenteredcareincludesnon-pharmacologicaltreatmenttoaugmenttraditionaltherapy
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Recommendations:• GiventhebehavioralconsequencesofnottreatingPTSD:• Screeningforrecentandpasttrauma,PTSD• ScreeningshouldbepartofthecorecomponentsofHIV
treatment• Interventionstoincreaseresiliencethroughself-efficacy• Increasingaccesstointegrated,traumainformedmentalhealth,
addictiontreatmentandHIVcare
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Suggestedreading:
• TheBodykeepstheScoreBrain,MindandBodyintheHealingofTrauma• BesselVanDerKolk MD
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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.