Download Disclosure Statement Presentation Topics

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.
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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
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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
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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
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DSM‐PTSD CON’T
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D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) o
the following: •
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Discuss Post Traumatic Stress Disorder
difficulty falling or staying asleep
irritability or outbursts of anger difficulty concentrating Hypervigilance exaggerated startle response
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E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
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F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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Specify if:
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Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
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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:
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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: •
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•
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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)
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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
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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
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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
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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).
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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
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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
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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
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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
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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
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Psychobiological Techniques for Stress Management
Integrative Medicine ‐ mixture of both conventional medicine and CAMs
How Do we Help?
“Best of both worlds” 12
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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
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