POST TRAUMATIC STRESS DISORDER

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 24103-113
• 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.
  1595-11, 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 DISORDERShould be viewed
as a treatable condition

• POST
• TRAUMATIC
• STRESS
• DISORDER

• Remember it is
• PAINFUL
• TREATABLE
• SENSORY
• DYSFUNCTION

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 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

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) 6715-25.
• 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 Brocas 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 dont 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 20053511 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 20053511 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
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

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
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

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
  1S97-120.

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/Bisexual
Men (N61)

• 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 (N61)

• 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 (N61)

• 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 (N102)

• 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 1233-245.

51

• TREAMENT

52
TREATMENT

• PTSD Treatment requires care from
• experienced mental health
• Professionals.

53
TREATMENT

• Strategies must include treatment for
• co-existing mood and anxiety
• disorders, alcohol and substance use
• disorders.
• VA National Center for PTSD

54
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)

55
PTSD TREATMENT MODALITIES

• PHARMACOTHERAPY
• Sertraline and Paroxetine are FDA approved for
  treatment of PTSD
• Other SSRIs
• Topiramate (Topramax) and other anticonvulsants
• TCAs

56
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

57
PTSD TREATMENT MODALITIES

• CAUTION ADVISED
• Benzodiazepines
• Use short term
• Close monitoring
• Abuse potential
• Disinhibition, especially in those with severe
  dissociative symptoms

58
SUPPORTIVE RESOURCES

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

59

• TREATMENT GOALS

60
TREATMENT GOALS

• Build trusting patient-clinician relationships
• Optimize health and well being

61
TREATMENT GOALS

• Minimize symptoms
• Fully reintegrate a safe sense of self
• Improve adherence
• Improve CD4 and viral levels

62
TREATMENT GOALS

• Improve integration of care and communication
  among providers of care in order to maximize
  treatment success

63
INTEGRATION OF CARE
HIV Medical Care
INTEGRATION OF CARE
Substance Use Treatment Services
Mental Health Services
64

• THANK YOU

65
For more HIV-related resources, please visit
www.hivguidelines.org