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

What is Trauma?

   An event or series of events that threaten you, perhaps even with death and/or integrity – that causes physical or emotional harm and/or exploits your body 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): 35-45 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)

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 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

 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



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 HIV Medical Care Mental Health Services

INTEGRATION OF CARE

Substance Use Treatment Services