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POSTTRAUMATIC STRESS DISORDER

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POSTTRAUMATIC STRESS DISORDER Powered By Docstoc
					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
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
MENTAL DISORDERS



      INTRODUCTION
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
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
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.
Diagnostic Criteria from DSM IV TR


         WHAT IS PTSD?
  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
SPECTRUM OF ANXIETY DISORDERS

    PTSD

    Adjustment disorder

    Obsessive compulsive disorder

    Panic disorder

    Generalized anxiety disorder


    Refer to Diagnostic Criteria DSM IV TR
  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.
POST TRAUMATIC STRESS DISORDER
Should be viewed as a treatable condition

                      Remember it is:


POST              =   PAINFUL
TRAUMATIC         =   TREATABLE
STRESS            =   SENSORY
DISORDER          =   DYSFUNCTION
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.
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.
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.”
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.
WHAT is PTSD?
   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
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.
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.
PTSD



   Key Screening Questions
   for the Busy Practitioner
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?
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
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
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
SUBSTANCE USE and PTSD
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
COCAINE DEPENDENCE
   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
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
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
ALCOHOL

   Alcohol worsens PTSD symptoms
      Emotional numbing
      Social isolation

      Anger and irritability

      Depression

      Hypervigilence


    VA National Center for PTSD
TOBACCO

 Smokers   twice as likely as
    non-smokers to suffer from
    PTSD



Archives of General Psychiatry (vol 62, p1258)
OCCUPATIONAL HIV EXPOSURE
        and PTSD
    OCCUPATIONAL HIV 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
    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
CHILDHOOD and PTSD
UNTREATED CHILDHOOD TRAUMA

 Associatedwith 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.
UNTREATED CHILDHOOD TRAUMA
 Characteristic 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.
PTSD - HIV
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.
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.
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.”
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.”
    PTSD RESPONSE TO HIV INFECTION
     Homosexual/Bisexual Men (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.
 PTSD RESPONSE TO HIV INFECTION
  Homosexual/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.
  PTSD RESPONSE TO HIV INFECTION
   Homosexual/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.
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.
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.
    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)
    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.
        PTSD-SUBSTANCE ABUSE
            DISORDERS- HIV

 Currentdrug 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.”
      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.
TREAMENT
TREATMENT


PTSD Treatment requires care from
experienced mental health
Professionals.
TREATMENT


Strategies must include treatment for
co-existing mood and anxiety
disorders, alcohol and substance use
disorders.


VA National Center for PTSD
PTSD TREATMENT MODALITIES

   Mental Health Care
       Pharmacotherapy
       Cognitive behavioral therapy
       Group treatment
       Psychodynamic treatment
       EMDR
       Light therapy (no proven benefit)
       Color therapy (no proven benefit)
PTSD TREATMENT MODALITIES
PHARMACOTHERAPY
    Sertraline and Paroxetine are FDA
     approved for treatment of PTSD

    Other SSRIs

    Topiramate (Topramax) and other
     anticonvulsants

    TCAs
PTSD TREATMENT MODALITIES

EMDR   (Eye Movement Desensitization and Reprocessing)

    Creates similar brain activity as REM
     (Rapid Eye Movement) during sleep

    REM assists in processing ideas and
     resolving conflicts
PTSD TREATMENT MODALITIES
   CAUTION ADVISED
       Benzodiazepines
           Use short term

           Close monitoring

           Abuse potential

           Disinhibition, especially in those with
            severe dissociative symptoms
SUPPORTIVE RESOURCES

    Mental Health Professionals
    Rape crises centers
    COBRA
    HIV Adult Day Treatment Centers
    Drug/Alcohol counseling and treatment
    Stable family connections
    Churches / Pastors
TREATMENT GOALS
TREATMENT GOALS


   Build trusting patient-clinician
    relationships

   Optimize health and well being
TREATMENT GOALS

   Minimize symptoms

   Fully reintegrate a safe sense of self

   Improve adherence

   Improve CD4 and viral levels
TREATMENT GOALS


   Improve integration of care and
    communication among providers of
    care in order to maximize treatment
    success
         INTEGRATION OF CARE




                   HIV
                Medical Care


                INTEGRATION
                   OF CARE
Mental Health                    Substance Use
  Services                     Treatment Services
THANK YOU
 For more HIV-related resources,
please visit www.hivguidelines.org