Download POSTTRAUMATIC STRESS DISORDER

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?

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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)

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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?
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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
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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

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62% have experienced at least one traumatic event PreHIV 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):110120.
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
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Elevated VL / poor response to HAART
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Poor adherence
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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
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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
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Mental Health Care
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Pharmacotherapy
Cognitive behavioral therapy
Group treatment
Psychodynamic treatment
EMDR
Light therapy (no proven benefit)
Color therapy (no proven benefit)
SUPPORTIVE RESOURCES
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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
INTEGRATION
OF CARE
Mental Health
Services
Substance Use
Treatment Services