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POST TRAUMATIC STRESS DISORDER

POST TRAUMATIC STRESS DISORDER. The Hidden Epidemic in People with HIV Infection Developed by: L. Jeannine Bookhardt-Murray, MD Contributions by: Douglas Fish, MD Michael Mendola, PsyD Shane Spicer, MD Wanda McCoy, MD Mollie Anne Jacobs.

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POST TRAUMATIC STRESS DISORDER

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  1. POST TRAUMATIC STRESS DISORDER The Hidden Epidemic in People with HIV Infection Developed by: L. Jeannine Bookhardt-Murray, MD Contributions by: Douglas Fish, MD Michael Mendola, PsyD Shane Spicer, MD Wanda McCoy, MD Mollie Anne Jacobs

  2. MAIN POINTS Description of PTSD PTSD in the General Population PTSD-HIV PTSD negatively impacts health of people with HIV infection Diagnostic criteria PTSD screening questions Co-occurring mental disorders  Treatment options

  3. MENTAL DISORDERS INTRODUCTION

  4. GOOD MENTAL HEALTH “The successful performance of mental function, resulting in productive activities fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity; from early childhood until late life, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience and self esteem.” HRSA

  5. RISKS FOR MENTAL ILLNESS • Chronic illnesses, including HIV infection • Early life trauma • Drug and alcohol addiction • Homelessness • Perpetrator or recipient of violent acts • Incarceration / Institutionalization • Poverty • Physical disabilities • Chronic pain

  6. MENTAL ILLNESSES ARE ASSOCIATED WITH POORER PHYSICAL HEALTH OUTCOMES Most studies done in depression (24% increased risk of death w/in 6 years of diagnosis) Int J Psych Med 1994; 24:103-113 Osborn, David P. J. “The Poor Physical Health of People with Mental Illness”. West J Med 175(5):329-332, 2001. Smith, Michael T. PhD, et. al. “Comparative Meta-Analysis of Pharmacotherapy and Behavior Therapy for Persistent Insomnia. Am J Psychiatry. 159:5-11, 2001.

  7. Diagnostic Criteria from DSM IV TR WHAT IS PTSD?

  8. MOOD AND ANXIETY DISORDERS 21% of adult Americans will suffer mood and anxiety disorders during their lifetimes PTSD is an anxiety disorder Mental Health in Adulthood www.surgeongeneral.gov

  9. SPECTRUM OF ANXIETY DISORDERS • PTSD • Adjustment disorder • Obsessive compulsive disorder • Panic disorder • Generalized anxiety disorder Refer to Diagnostic Criteria DSM IV TR

  10. POSTTRAUMATIC STRESS DISORDER BASIC CRITERIA A. Exposure to a traumatic event that threatened death, serious injury resulting in intense fear, helplessness, or horror B. Traumatic event persistently re-experienced with physiological responses C. Persistent avoidance of stimuli associated with the trauma D. Persistent symptoms of increased arousal E. Duration of disturbance more than 1 month F. Clinically significant impairment in social, and occupational environments, etc.

  11. POST = TRAUMATIC = STRESS = DISORDER = Remember it is: PAINFUL TREATABLE SENSORY DYSFUNCTION POST TRAUMATIC STRESS DISORDERShould be viewed as a treatable condition

  12. CASE Ms. “P” was walking down the street with her child when a stray bullet hits her child in the chest and instantly kills the child. Ms. “P” recalls nothing of the event except that she heard her child say, “Blood Mommy,” as she fell to the sidewalk. Ms. “P” was taking her child to school and from there was to see her HIV doctor. Ms. “P” had a 10 year relationship with her doctor with no substance use history or adherence problems. Previously she had been totally focused on maintaining good health and being the best mother possible. She had been a model patient.

  13. CASE Continued She never made it to the clinic that day and after multiple failed outreach attempts Ms. “P” was lost to follow up. She reappeared at clinic almost a year later when she had self discontinued HAART, her CD4 was 122 down from 595, viral load was up (54,000) after being undetectable for 5 years. At several appointments she merely told her MD that her 9 year old daughter had died. He was empathetic but did not probe, thinking it would upset her.

  14. CASE Continued She resumed HAART but missed doses and medical appointments and fell into the “difficult patient” category. She denied depression, feeling nervous, and was not suicidal or homicidal. She did report nightmares, social isolation, and fear of walking down certain streets as well as fear of coming to the clinic. While in the waiting room she frequently experienced palpitations, jitters, SOB, and would sometimes leave w/o being seen. The staff dubbed her “drama queen.”

  15. CASE Continued In review of the medical record and case discussion it became clear that there was an abrupt change in her pattern of keeping appointments and taking her medication. At a subsequent visit her doctor used a mental health screening tool and discovered symptoms of depression and PTSD. A mental health referral was generated. The outcome is unclear because Ms. “P” moved to Georgia to be closer to her family.

  16. WHAT isPTSD? • Significant alterations between re-experiencing the traumatic event, avoidance and numbing, along with increased arousal and startle responses • Most cases of PTSD spontaneously resolve • Risk factors may predispose to persistent and worsening symptoms • PTSD often coexists with depression, anxiety disorders, somatization and substance abuse/dependence

  17. WHAT is PTSD? • Neurobiological changes occur at the time of the event • Sensitization of the hypothalamic pituitary adrenal axis (HPA) with paradoxical decrease in cortisol release Foa, E. B. et al. “Symptomatology and Psychopathology of Mental health Problems After Disaster. Journ of Clin Psych (2006) 67:15-25. Yehuda, R. (2001) “Biology of Posttraumatic Stress Disorder.” Journal of Clinical Psych 62(17):41-46.

  18. IMAGING STUDIES and PTSD MRI findings may represent pre-trauma vulnerability or consequence of traumatic events • Non-specific white matter lesions • Decreased hippocampal volume PET findings • Increased activation of amygdala 7 anterior paralimbic structures (emotions) • Greater deactivation Broca’s area (speech) Bremner JD, Randall P, et al. Magnetic resonance imaging-based measurement of hippocampal volume in posttratumatice stress disorder related to childhood physical and sexual abuse-a preliminary report. Biological Psychiatry Vol 41, Issue 1, Jan 1997 pp 23-32.

  19. PTSD Key Screening Questions for the Busy Practitioner

  20. In your life have you ever experienced an event that was so horrible, upsetting or frightening that you: Have nightmares about it or think about it when you don’t want to? Try hard not to think about it or go out of your way to avoid situations or places that remind you of it? Find yourself constantly on guard or easily startled? Feel numb or detached from others or your surroundings? Are these changes associated with physiological changes?

  21. COMMONLY CO-OCCURING DISORDERS Important to screen for co-occurring psychiatric conditions: • Depression • Anxiety Disorders • Psychotic disorders • Bipolar disorders • Personality disorders • Immediate harm to self or others

  22. PTSD and the GENERAL POPULATION • 50% of adults and children have been exposed to traumatic events that could lead to PTSD • 12-50% of those exposed to trauma will develop PTSD Davidson,J, Bernik, M, et al. “A New Treatment Algorithm for Posttraumatic Stress Disorder” Psych Annals Nov 2005;35:11: 887-898

  23. PTSD and the GENERAL POPULATION • 8% prevalence in general population • Chronic course develops in up to 50% Davidson,J, Bernik, M, et al. “A New Treatment Algorithm for Posttraumatic Stress Disorder” Psych Annals Nov 2005;35:11: 887-898

  24. SUBSTANCE USE and PTSD

  25. SUBSTANCE USE • Concurrent substance use disorder in 24-40% of individuals • Substance abuse worsens course of mental illness Mental Health in Adulthood” www.surgeongeneral.gov

  26. COCAINEDEPENDENCE • 30-50% meet criteria for lifetime PTSD • Associated with increased rates of exposure to previous trauma • Associated with HIV high risk behaviors Back, S.E. et al. “Exposure therapy in the treatment of PTSD among cocaine dependent individuals .” J Subst Abuse Treatment (20010 21 (1): 35-45 Brief DJ, et al. “Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes.” AIDS Care 16 Suppl 1: S97-120

  27. ALCOHOL • Women exposed to trauma have increased risk for alcohol disorder • Women with alcohol disorder increased histories of sexual abuse VA National Center for PTSD

  28. ALCOHOL • Men and women with histories of sexual abuse have higher rated of alcoholism and substance use than those who have not VA National Center for PTSD

  29. ALCOHOL • Alcohol worsens PTSD symptoms • Emotional numbing • Social isolation • Anger and irritability • Depression • Hypervigilence VA National Center for PTSD

  30. TOBACCO • Smokers twice as likely as non-smokers to suffer from PTSD Archives of General Psychiatry (vol 62, p1258)

  31. OCCUPATIONAL HIV EXPOSURE and PTSD

  32. OCCUPATIONALHIV EXPOSURE AND PTSD • Two healthcare workers developed disabling chronic PTSD after needle stick exposure (22 months later) • PTSD despite repeatedly negative HIV antibody tests Worthington, M. G. et al. (2006)”Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review.” Infec Con Hosp Epi 27(2):215-217

  33. OCCUPATIONAL HIV EXPOSURE AND PTSD • Need for evaluation of role for long term psychological follow up, counseling and support Worthington, M. G. et al. (2006)”Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review.” Infec Con Hosp Epi 27(2):215-217

  34. CHILDHOOD and PTSD

  35. UNTREATED CHILDHOOD TRAUMA • Associated with HIV high risk behaviors Allers, C.T. et al. (1993) “HIV vulnerability and the adult survivor of childhood sexual abuse.” child Abuse Negle 17(2): 291-8.

  36. UNTREATED CHILDHOOD TRAUMACharacteristic Abuse Symptoms • Chronic depression • Sexual compulsivity • Revictimization • Substance abuse Allers, C.T. et al. (1993) “HIV vulnerability and the adult survivor of childhood sexual abuse.” child Abuse Negle 17(2): 291-8. Cohen, MA, Alfonso, CA et al. “The impact of PTSD on treatment adherence in persons with HIV infection.” Gen Hosp Psych 23 (5): 294-6.

  37. PTSD - HIV

  38. PTSD-HIV • Many exposed to some type of traumatic lifetime event • Substantial numbers substance use disorders • Behaviors negatively impact immune system and outcomes Brief, D. J. et al. “Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes.” AIDS CARE (2004) 16 Supplement 1:S97-120.

  39. PTSD-HIV • 62% have experienced at least one traumatic event Pre-HIV that met DSM-IV PTSD criteria • Significant percentage of people experienced physical harm Post-HIV because of HIV status, harmed by someone close Boarts. J. M. “The differential impact of PTSD and depression on HIV disease markers and adherence to HAART in people living with HIV.” AIDS and Behavior, Vol 10, No. 3, May 2006; 253-261.

  40. PTSD-HIV People living with HIV have disproportionately higher rates of PTSD and depression: • Compared to people without HIV • Compared to people with other chronic diseases Boarts. J. M. “The differential impact of PTSD and depression on HIV disease markers and adherence to HAART in people living with HIV.” AIDS and Behavior, Vol 10, No. 3, May 2006; 253-261. Uldall, K. K. et al. AIDS Care 2004; 16 (supplement 1) S71-S96 “Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature.”

  41. PTSD-HIV • May experience faster rates of disease progression, especially if PTSD complicated by depression • The longer a person lives with HIV the greater the likelihood s/he will develop an anxiety disorder • Over 50% of PLWHA found to have PTSD in a community setting • Boarts. J. M. “The differential impact of PTSD and depression on HIV disease markers and adherence to HAART in people living with HIV.” AIDS and Behavior, Vol 10, No. 3, May 2006; 253-261. Uldall, K. K. et al. AIDS Care 2004; 16 (supplement 1) S71-S96 “Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature.”

  42. PTSD RESPONSE TO HIV INFECTIONHomosexual/BisexualMen (N=61) Associated with: • Pre-HIV PTSD from other causes • Pre-HIV psychiatric diagnosis Kelly, B. et al. (1998). “Posttraumatic stress disorder in response to HIV infection.” Gen Hosp Psych 10(6):345-52.

  43. PTSD RESPONSE TO HIV INFECTIONHomosexual/Bisexual Men (N=61) • 30% met criteria for PTSD after HIV infection diagnosis Kelly, B. et al. (1998). “Posttraumatic stress disorder in response to HIV infection.” Gen Hosp Psych 10(6):345-52.

  44. PTSD RESPONSE TO HIV INFECTIONHomosexual/Bisexual Men (N=61) Associated with: • Post-HIV PTSD diagnosis associated with other psychiatric disorders, particularly first episode of major depression after HIV diagnosis Kelly, B. et al. (1998). “Posttraumatic stress disorder in response to HIV infection.” Gen Hosp Psych 10(6):345-52.

  45. Sample of HIV Infected Women (N=102) Increased risk for PTSD associated with: • Pre-HIV trauma • Greater degree of negative life events • Perceived inadequate social support • Greater degree of perceived stigma Katz, S. et al. “Risk factors associated with posttraumatic stress disorder symptomatology in HIV infected women.” AIDS patient CARE STDS (20050 19(2):110-120.

  46. PTSD and MEDICATION ADHERENCE PTSD Associated with: • Medication adherence problems • Death anxiety • Depression Bottonari, K. A. et al. (2005). “Life stress and adherence to antiretroviral therapy among HIV-Positive individuals: A preliminary investigation.” AIDS Patient Care and STDs 19(110: 719-727. Safren, S. A. et al. (2003). “Symptoms of posttraumatic stress and death anxiety in persons with HIV and medication adherence difficulties.” AIDS Patient Care STDS 17(12): 657-664.

  47. PTSD ASSOCIATED WITH RISKS FOR POORER HEALTH OUTCOMES • Fluctuation in CD4 • Elevated VL / poor response to HAART • Poor adherence • Unexplainable symptoms, including pain • Exacerbation of other health problems (DM, Cancer, HTN, Heart Disease)

  48. PTSD and DEPRESSION IMPACT HIV STABILITY • Poor adherence to HAART • Detectable Viral loads • Lower T-cells Boarts J. M., Sledjeski E. M., Bogart L. M., Delahanty D. L. The Differential Impact of PTSD and Depression on HIV Disease Markers and Adherence to HAART in People Living with HIV. AIDS and Behavior , Vol. 10, No. 3, May 2006, pp. 253-261.

  49. PTSD-SUBSTANCE ABUSE DISORDERS- HIV • Current drug or alcohol use negatively impacts adherence to ARVT Uldall, K. K. et al. AIDS Care 2004; 16 (supplement 1) S71-S96 “Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature.”

  50. PTSD-SUBSTANCE ABUSE and HIV INFECTED WOMEN • 35% PTSD current disorder • 38% PTSD lifetime disorder Mellins, C.A., Ehrhardt, A.A., Grant, W.F. Psychiatric symptomatology and psychological distress in HIV-infected mothers. AIDS and Behavior, 1997; 1:233-245.

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