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2/24/2017 Disclosure Statement I, do not have a vested interest in or affiliation with any corporate organization offering financial support or grant money for this continuing education program, or any affiliation with an organization whose philosophy could potentially bias my presentation. 3 Presentation Topics “Achieving Health Equity through Inter‐professional Care: Focus on U.S. Veterans.” “Management of Stress among U.S. Military Veterans • The Stress Management Presentation will address the following objectives: • Define stress and types of stress conditions • Discuss Post Traumatic Stress Disorder • Describe the physiological and psychological impact of stress on health; • Explain the current research related to allostatic load and the implication for health disparities • Discuss Resilience and recovery from traumatic stress • Psychobiological Techniques for Stress Management Dr. DeAnna M. Burney, Professor Florida A&M University February 24, 2017 1 2/24/2017 Presentation Objectives • Upon completion of this CE activity, the pharmacist should be able to: Describe the physiological and psychological impact of stress on health; explain the current research related to allostatic load and the implication for health disparities; and explain how improved mental health improves overall health outcomes. “When we were children, we used to think that when we were grown up we would no longer be vulnerable. But to grow up is to accept vulnerability.. to be alive is to be vulnerable”. • Upon completion of this CE activity, the technician should be able to: Define allostatic load; List non‐pharmacological options used to manage stress; and list common symptoms associated with stress. Madeleine L’Engle Define stress and types of stress conditions 2 2/24/2017 National Causes of Stress Stress is an Intensified Event Celebs on '23 Ways You Could Be Killed if You Are Black in America' Personal Causes of Stress What is Stress? • Stress: nonspecific response of the human organism to any demand made upon it. • Stressor: factor or condition causing stress. • Acute stress: body’s response to imminent danger – • most common type. • Chronic stress: caused by prolonged physical or emotional stress, more than can be coped with. • Distress: negative stress • Eustress: positive stress 3 2/24/2017 DSM‐PTSD CON’T • D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) o the following: • • • • • Discuss Post Traumatic Stress Disorder difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating Hypervigilance exaggerated startle response • E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. • F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Specify if: • • • Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more Specify if: • With Delayed Onset: if onset of symptoms is at least 6 months after the stressor. DSM‐IV‐TR Diagnostic Criteria for Posttraumatic Stress Disorder • A. Exposed to a traumatic event in which both of the following were present: • experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a DREAMS threat to the physical integrity of self or others • response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior • B. Persistent reexperience in one (or more) of the following ways: • • • • • • Recollections: images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Dreams Note: In children, there may be frightening dreams without recognizable content Acting or feelings of “reoccurance” (sense of reliving the experience, illusions, hallucinations, dissociative flashback episodes, including when intoxicated). Note: In young children, trauma‐specific reenactment may occur. Re‐experiencing the event Emotional effects Psychological distress at exposure to internal or external cues Physiological reactivity on exposure to internal or external cues C. Avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: • • • • • • • Detachment efforts to avoid thoughts, feelings, or conversations associated efforts to avoid activities, places, or people that arouse recollections Avoidance Month in Duration Sympathetic hyperactivity or hypervigilance inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) 4 2/24/2017 The Dynamics Between Stress and Disease Three Different Types of Stress Injuries • To understand the relationship between stress and disease, one Combat/Operational Stress needs to understand that several factors act in unison to create a pathological outcome including: Stress Adaptations Positive Behaviors Negative Behaviors Stress Injuries Traumatic Stress Operational Fatigue Grief Injury • • • • Cognitive perceptions of a threatening stimuli Activation of the sympathetic nervous system Engagement of the endocrine system Engagement of the immune system Due to a Due to the Due to the Due to terrifying or wear and tear loss of friends physical injury horrible event of deployment and leaders limited functioning Physiology of the Stress Response Describe the physiological and psychological impact of stress on health Once stress is perceived, the sympathetic division of the ANS is activated and mobilizes the body’s resources “Flight or fight” response ‐ the body is readying to either attack or escape 5 2/24/2017 Perception • Is a person’s interpretation of reality. • People with different personalities perceive things differently. (agreeable, open, neurotic, psychotic) • Perception is influenced by heredity, environment, personality, intelligence, needs, self concept, attitudes, and values. “Stress” Hormones • Cortisol • Can be used as an index of stress • Assess in saliva and urine • Norepinephrine • Both a hormone and a neurotransmitter (produced in many places in the body) • Epinephrine • Produced in the adrenal medulla • Used as an index of stress • Measured in urine Serotonin and Mental Health Neuro‐hormones INFLUENCE ON THE BODY 6 2/24/2017 The General Adaptation Syndrome Explain the current research related to allostatic load and the implication for health disparities General Adaptation Syndrome 1. Alarm This is any signal that is recognized as stress. This causes the activation of adrenal glands. 2. Resistance This takes place as your body tries to adjust to the stressful event. Readjustment of your body to a normal state. This is called “homeostasis.” What is Allostasis? • Homeostasis implies that an organism remains within a certain range of physiological parameters to maintain stable function. • Allostasis implies that an organism constantly varies and adjusts physiological parameters to maintain stable function. 3. Exhaustion Once you have experienced a stressful event, have you ever felt like you could sleep for days? Exhaustion allows your body to heal itself, and recharge its batteries. If this stage is not complete, sickness or death could result. (Allostatic Load). 7 2/24/2017 Allostatic Load Stress and Disease • Allostasis is an alternative hypothesis that takes environmental Negative emotions and health-related consequences stimuli into account. • Allostasis could this consturct imply that homeostasis is an unrealistic goal? (a pipe dream)? Negative emotions Stress hormones Unhealthy behaviors (smoking, drinking, poor nutrition and sleep) Health Despairing Conditions – Cancer Types Immune suppression Autonomic nervous system effects (headaches, hypertension) Allostatic Load and Health “Homeostasis emphasized that the body’s internal environment is held constant by the self‐correcting (negative feedback) actions of its constituent organs. Allostasis emphasizes that the internal milieu varies to meet perceived and anticipated demand. This variation is achieved by multiple, mutually reinforcing neural and neuroendocrine mechanisms that override the homeostatic mechanisms. The allostatic model, in emphasizing the subordination of local feedbacks to control by the brain, provides a strong conceptual framework to explain social and psychological modulation of physiology and pathology.” Peter Sterling and Joseph Eyer, 1988 • Diabetes • • Cardiovascular disease • • Rheumatoid arthritis • • Depressive disorders • • PTSD (e.g., Gallo et al., 2014; Juster et al., 2011; Pace & Heim, 2011) A 8 2/24/2017 Crisis Theory of Chronic Illness – A Model Discuss Stress as a risk factor for physical illness Background and Personal Factors Illness-related Factors Cognitive Appraisal Adaptive Tasks Physical and Social Environmental Factors Chronic Illness as a Crisis • Illness is a crisis because it is a turning point in an individual’s life. • Disruption to established patterns of personal and social functioning produces a state of psychological, social, and physical disequilibrium • Adaptation = finding new ways of coping with drastically altered circumstances. Restore equilibrium. Coping Skills Outcome of Illness Adherence Crisis Theory (Moos, 1982) • A model describing the factors that affect people’s adjustment to having serious illness. • Coping process (3 stages) is influenced by 3 factors • Illness‐Related Factors • Background and personal Factors • Physical and Social Environment Factors • Coping process influences outcome of crisis 9 2/24/2017 Frequency of Possible Diagnoses Among OEF and OIF Veterans Diagnosis (n = 347,750) (Broad ICD-9 Categories) Frequency * % Infectious and Parasitic Diseases (001-139) 40,956 11.8 Malignant Neoplasms (140-208) 3,248 13,910 4.0 Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 75,850 21.8 Diseases of Blood and Blood Forming Organs (280-289) 7,675 2.2 Mental Disorders (290-319) 147,744 42.5 Diseases of Nervous System/ Sense Organs (320-389) 121,473 34.9 56,900 16.4 Diseases of Circulatory System (390-459) Disease of Respiratory System (460-519) Disease of Digestive System (520-579) Diseases of Genitourinary System (580-629) Diseases of Skin (680-709) 71,087 20.4 110,449 31.8 37,118 10.7 55,797 16.0 Diseases of Musculoskeletal System/Connective System (710-739) 165,439 47.6 Symptoms, Signs and Ill Defined Conditions (780-799) 138,043 39.7 Injury/Poisonings (800-999) 73,767 Cognitive and emotional changes associated with Stress 0.9 Benign Neoplasms (210-239) 21.2 *These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2008; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 347,750. Traumatic Events in OEF/OIF • • • • • • • • • • • • Multi‐casualty incidents (SVBIEDs, ambushes) Friendly fire Death or maiming of children and women Seeing gruesome scenes of carnage Handling dead bodies and body parts “Avoidable” casualties and losses Witnessed or committed atrocities Witnessed death/injury of a close friend or leader Killing unarmed or defenseless enemy Being helpless to defend or counterattack Injuries or near misses Killing someone up close 10 2/24/2017 Beliefs That Can Be Damaged By Traumatic Stress Emotional Symptoms of Stress Belief in one’s basic safety Belief in being the master of oneself and one’s environment Belief in “what’s right” — moral order Belief that our cause is honourable Belief that every troop is valued Belief in the basic goodness of people (especially oneself) • Anxiety • Depression • Flat affect • Heightened anger • Panic attacks Cognitive Symptoms of Stress • Memory/concentration difficulties • Difficulty problem solving • Feelings of helplessness/hopelessness • Denial Discuss Resilience and recovery from traumatic stress 11 2/24/2017 Psychobiological Techniques for Stress Management Integrative Medicine ‐ mixture of both conventional medicine and CAMs How Do we Help? “Best of both worlds” 12 2/24/2017 Treatment: PTSD • Requires multiple modalities • Initial education, support and referrals important to establish trust • Pharmacotherapy • Psychotherapy • Relaxation Training Treatment: PTSD‐Pharmacotherapy • Duration of at least 8‐12 weeks • Adequate dosages • Maintenance treatment for at least 1 year • Antidepressants • Mood stabilizers • Propranolol, clonidine • Atypical antipsychotics QUESTION & ANSWER 13