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PTSD, Trauma, HIV

PTSD, Trauma, HIV. April 16, 2013 Nathan Smith Clinic. Topics for Discussion. Relationship between Trauma and HIV Medication Adherence? Definition of Trauma vs. PTSD vs. Complex Developmental Trauma Physical and Psychological Manifestations An Overview of Treatment Options. Trauma and HIV.

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PTSD, Trauma, HIV

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  1. PTSD, Trauma, HIV April 16, 2013 Nathan Smith Clinic

  2. Topics for Discussion Relationship between Trauma and HIV Medication Adherence? Definition of Trauma vs. PTSD vs. Complex Developmental Trauma Physical and Psychological Manifestations An Overview of Treatment Options

  3. Trauma and HIV Wagner et al., (2003), studying compliance issues among HIV-positive persons with serious mental illness, found that 40% of his sample had a 90% compliance rating as measured b electronic monitoring; however, 31% of his sample had less than 50% adherence. Boarts et al. (2006) found, compared to non-psychiatrically-diagnosed patients, those with depressive symptoms presented with lower CD4 counts and a detectable viral load. Patients with comorbid PTSD and depression were less compliant with HAART and more likely to have a detectable viral load. Vranceanu et al. (2008) found depression to have a primary role and PTSD a secondary role in poor medication adherence in HIV treatment. Smith et al., (2002), comparing a number of pain indices among HIV-infected patients with and without PTSD symptoms, found that the PTSD sample rendered significantly higher pain intensity ratings, greater pain interference in daily activity scores, and poorer mood and interpersonal relations scores.

  4. Trauma in HIV+ Women • Psychological Trauma and PTSD in HIV-Positive Women: A Meta-Analysis; E. L. Machtinger, T. C. Haberer, J. E. Wilson, and D. S. Weiss; AIDS and Behavior (2012) • The findings demonstrate disproportionate rates of trauma exposure and recent PTSD in HIV-positive women compared to the general population of women. For example, the estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8–42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women. The estimated rate of intimate partner violence is 55.3% (95% CI 36.1–73.8%), which is more than twice the national rate.

  5. What is Trauma? “outside the range of the usual human experience” (1980 APA) but are rape, domestic violence, abuse, war, displacement really such a marginal part of human experience? “common denominator is a feeling of intense fear, helplessness, loss of control and a threat of annihilation”(Comprehensive Txt Psychiatry) Overwhelm ordinary human adaptations to life Involve threats to life or bodily integrity or a close personal encounter with violence and death

  6. PTSD DSM-IV Criteria A) Exposure to traumatic event with Actual or threatened death or serious injury and • Response involving intense fear, helplessness, or horror • Re-experiencing the traumatic event • Persistent avoidance of stimuli associated with event • Numbing of general responsiveness • Symptoms of increased arousal • At least 1 month’s duration (otherwise can diagnose Acute Stress Disorder) • Significant distress or impairment in social, occupational, or other functioning American Psychiatric Association. DSM-IV. 1994.

  7. Depression Psychosis Personality Disorder Substance Use Disorders Panic Disorder PTSD Somatization Obsessive Compulsive Disorder Dissociation Diagnostic Spectrums

  8. Signs and Symptoms of PTSD • Social impairment, detachment, loss of interest • Memory deficits • Concentration difficulty • Numbing, referred to as “a freezing of the heart” • “Hundred mile stare” • Anger outbursts • Feelings of intense guilt • Recurrent dreams/nightmares/frightening thoughts • Sleep disorders

  9. Physiological Responses to Trauma • Fight or Flight or Flee • Sympathetic Increase/Hyperaroused State: HR, BP up, Dilation up, Disregard Hunger, Fatigue, Pain --> Remain Lasting • Hyperarousal (“self preservation on permanent alert”) • Startles easily, reacts irritably to small provocations, sleeps poorly, hypervigilant, nightmares, cannot “tune out” repetitive stimuli that other people would find annoying • Even single traumatic events appear to recondition the human nervous system

  10. Physical Changes Found In PTSD • Elevated levels of stress hormones noradrenaline and adrenaline • Hyperactive sympathetic nervous systems; exaggerated increases in heart rate and blood pressure. • Reduction in the volume of the hippocampus and amygdale region of the brain (emotions, learning and memory).

  11. Impact of Childhood Traumaon Early Development • Interferes with development of secure Attachments • Magnifies childhood anxieties and fears • Inadequate stimulus barrier impairs development of basic trust • Leads to negative self-image and sense of self • Difficulty with body image formation

  12. Epidemiology of PTSDNational Comorbidity Study 7.8% of adults in the U.S. (lifetime) Type of trauma most often the basis for PTSD: rape in women (46% risk) combat in men (39% risk) 1/3 of cases have duration of many years 88% of cases have psychiatric comorbidity Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.

  13. Primary Psychiatric Disorder 6 Months Following Trauma Responses to Trauma Are Heterogeneous 80 70 60 Number of Individuals 50 40 30 20 10 0 MDD Eating Panic PTSD Anxiety No Disorder Drug Abuse McFarlane, et al. Ann N Y Acad Sci. 1997;821:437-441

  14. 94% 47% 42% 30% ? Longitudinal Course of PTSD Symptoms % with PTSD Symptoms W 3m 9m Years Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-60.

  15. Twelve-Month Prevalence of DSM-IVMajor Psychiatric Disorders % Mood Disorders Major depressive episode 6.7 Dysthymia 1.5 Manic episode 2.6 Anxiety Disorders Social Phobia 6.8 Simple Phobia 8.7 PTSD 3.5 Agoraphobia without panic 0.8 GAD 3.1 Panic disorder 2.7 Substance Use Disorders Alcohol abuse/dependence 4.4 Drug abuse/dependence 1.8 Adapted from Kessler RC, et al. Arch Gen Psychiatry. 2005;62:617-627.

  16. Witness Accident Threat w/ Weapon Physical Attack Molestation Combat Rape Prevalence of Trauma and Probability of PTSD 1 2 1. Kessler R et al. J Clin Psychiatry. 2000;61(Suppl 5):4-14. 2. Kessler R et al. Arch Gen Psychiatry. 1995;52:1048-1060.

  17. Risk Factors for PTSD • Severity of trauma (ie, threat, duration, injury, loss) • Prior traumatization • Gender • Ethnicity • Prior mood and/or anxiety disorders • Family history of mood or anxiety disorders • Education

  18. Early Post-Trauma Interventions • Crisis Interventions—Short cognitive behavioral therapy (CBT): • Psychological Debriefing—equivocal or harmful • Cognitive Behavioral Prevention Programs: • Prolonged Exposure (PE) • Prolonged Exposure + Stress Inoculation Training (PE/SIT) • Psychotherapy • Brief dynamic psychotherapy for traumatic grief • Supportive counseling • Spiritual counseling • Pharmacotherapy • Propranolol • Foa EB, et al. J Clin Psychiatry. 1999;60(suppl 16):1-34. • Mitchell JT. JEMS. 1983;8:36-9.

  19. Meta-analysis of Pharmacotherapy for PTSD • 35 RCTS with 17 positive placebo-controlled trials • Medication response in 59.1% • Placebo response in 38.5% • SSRIs most effective • Medication effects greater for co-morbid depression and disability • 3 maintenance trials suggest long-term medication

  20. Adrenergic-Inhibiting Agents: Alpha1-Adrenergic Blockers • Prazosin* 7 to 15 mg qhs • Alpha1- post-synaptic adrenoceptor receptor antagonist • Alpha1 receptors widely distributed in the brain, including the amygdala and hippocampus • Alpha1 receptors modulate sleep and startle responses • Double-blind RCT in 40 veterans, 13.3 +/- 3 mg 1 • Robust improvement in sleep quality and distressing dreams • Medium to large effect size in each PTSD Sx cluster • Adverse reactions include: syncope, dizziness, drowsiness, decreased energy, headache *Not FDA approved for the treatment of PTSD 1. Raskind, et al. Biol Psychiatry. 2007; 61: 928-34.

  21. Psychological Treatments for Chronic PTSD • Psychotherapy • Exposure therapy • Cognitive processing therapy • Anxiety management • Additional treatments • Eye Movement Desensitization and Reprocessing (EMDR) • Hypnotherapy • Psychodynamic therapy • Expressive therapies

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