post traumatic stress disorder the hidden epidemic in people with hiv infection developed by: l....

POST TRAUMATIC STRESS DISORDER

The Hidden Epidemic in People with HIV Infection

Developed by: L. Jeannine Bookhardt-Murray, MDContributions by:Douglas Fish, MD

Michael Mendola, PsyDShane Spicer, MDWanda McCoy, MDMollie Anne Jacobs

What is Trauma?

An event or series of events that threaten you, perhaps even with death – that causes physical or emotional harm and/or exploits your body and/or integrity

Trauma is pervasive and life-altering Trauma has been reported by 55-99% of

female substance abusers (Najavits et al, 1998)

Trauma betrays our beliefs, values, and assumptions – trust – about the world around us

Trauma leads us to engage in sometimes less healthy behaviors to help us through our reactions to these events. These behaviors Are an adaptation not a pathology

PTSD SYMPTOMS

Re-experience recurrent and intrusive recollections of and/or nightmares about the event

flashbacks, hallucinations, or other vivid feelings of the event happening again

great psychological or physiological distress when certain things (objects, situations, etc.) remind them of the event.

Avoidance persistently avoiding things that remind them of

the traumatic event including thoughts, feelings, or conversations associated with the incident to activities, places, or people that cause them to recall the event

general lack of responsiveness signaled by an inability to recall aspects of the trauma

decreased interest in formerly important activities

feeling of detachment from others, a limited range of emotion, and/or feelings of hopelessness about the future

Increased arousal Includes difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, becoming very alert or watchful, and/or jumpiness or being easily startled

Note: Folks w/PTSD are at increased risk for suicide

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

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): 35-45Brief 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


ALCOHOL

Alcohol worsens PTSD symptomsEmotional numbingSocial isolationAnger and irritabilityDepressionHypervigilence


TOBACCO

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

Archives of General Psychiatry (vol 62, p1258)

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.

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.

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 INFECTIONHomosexual/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.


30% met criteria for PTSD after HIV infection diagnosis



Associated with: Post-HIV PTSD diagnosis associated with other psychiatric disorders, particularly first episode of major depression after HIV diagnosis


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

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.”

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.

TREATMENT

PTSD Treatment requires care from experienced mental health Professionals.

Strategies must include treatment for

co-existing mood and anxiety disorders, alcohol and substance use disorders.

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)

SUPPORTIVE RESOURCES

Mental Health Professionals Rape crises centers COBRA HIV Adult Day Treatment Centers Drug/Alcohol counseling and

treatment Stable family connections Churches / Pastors

INTEGRATION OF CARE

INTEGRATION OF CARE

HIVHIVMedical CareMedical Care

Substance UseSubstance Use Treatment ServicesTreatment Services

Mental HealthMental HealthServicesServices

post traumatic stress disorder the hidden epidemic in people with hiv infection developed by: l....

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