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&parasympatheticsystems

• 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.