Novel Approach to Treating Stigma to Improve Mental Health and HIV Outcomes in Black Gay Men LaRon E. Nelson, PhD, RN, FNP, FNAP, FAAN Assistant Professor and Dean s Endowed Fellow in Health Disparities OHTN Research Chair in HIV Program Science Scientist, Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael s Hospital Toronto, Ontario, Canada
Stigma HIV stigma is a major obstacle to both primary and secondary HIV prevention Hostile attitudes regarding same-sex behavioral practices are common Intertwined with beliefs that HIV is punishment for same-sex behaviors
Stigma Five Domains Felt Normative Vicarious Internalized Anticipated Enacted
Stigma is stressful!! Source: JP Godbout, R Glaser (2006). Stress-induced immune dysregulation: Implications for wound healing, infectious disease and cancer. Journal of Neuroimmune Pharmacology, 1, 421-427.
Chronic Stress Response Activation Repeat exposures to stress Body s response does not reset Adaptive system becomes maladaptive Exerts load on the body s systems
STRESS AND IMMUNITY Legend: Acute and sustained psychosocial stress affects the circulation and activity of immuncompetent cells via the release of neuroendocrine mediators. The major neural efferent pathways, through which stress can affect peripheral immune functions, are the neocorticalsympathetic-immune axis Source: ME Kemeny, M. Schedlowski (2007). Understanding the interaction between psychosocial stress and immune-related diseases: A stepwise progression. Brain, Behavior, and Immunity, 21, 1009-1018.
Earnshaw Resilience Model
Stigma Other life events and circumstances are traumatic o HIV diagnosis acute/discrete o Stigma(s) Chronic o Homophobia-based violence - Chronic Stigma contributes to exacerbation and severity of HIV symptoms via the activation of physiological stress responses Interventions are needed to interrupt the pathway by which HIV stigma effects stress and HIV symptoms Nonetheless, significant gaps remain regarding the best strategies for supporting trauma-informed care among individuals with HIV
Stigma is stressful!! Chronic stressors as traumatic as traumatic stressors Stress symptoms consistent with PTSD symptoms, without traumatic life event Source: JP Godbout, R Glaser (2006). Stress-induced immune dysregulation: Implications for wound healing, infectious disease and cancer. Journal of Neuroimmune Pharmacology, 1, 421-427.
Post-Traumatic Stress Disorder (PTSD) DSM-V symptom clusters (all 4): (APA, 2013) 1) Re-experiencing memories of traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress 2) Avoidance of distressing memories, thoughts, feelings or external reminders of the event 3) Negative cognitions and mood distorted sense of blame of self or others estrangement from others or diminished interest in activities inability to remember key aspects of event 4) Arousal aggressive, reckless, or self-destructive behavior, hyper-vigilance, or related problems
Cerebral Cortex Cortex: Main site of permanent memory, which is very compactly coded. New memories must be filed near similar experiences. Permanent storehouse of semantic memories general time and context-independent (facts), (i.e. as opposed to episodic memory individual experiences).
Cerebral Cortex Hypothalamus: Central control center in the brain, including emotions Regulates visceral functions fighting, fleeing, feeding, and reproducing Two different autonomic nervous systems (ANS) --- Sympathetic: fight or flight --- Parasympathetic: rest and digest --- PTSD results in imbalanced ANS
Cerebral Cortex Hippocampus: Parsing and recording of momentary experiences Temporarily saves current experiences until they can be stored more permanently in the cortex Encoding of memories by hippocampus cannot be completely done (consolidated) without sleep Transference from short-to-long term memory
Cerebral Cortex Amygdala: Major role in processing and memory of emotional reactions and especially important events Bypasses the cortico-hippocampal route Coding of life-threatening events are burned into neural circuitry (e.g. life insurance policy for future survival) Direct encoding preserves all details (sights, sounds, smell, etc )
Routine Experience: Hypothalamus evaluates incoming stimuli and circumstances Hippocampus initial parsing and recording Memory consolidated via sleep (REM) Transference to the cortex Cortex permanent storage near similar experience Cortex Life or Death Experience: Hypothalamus evaluates incoming stimuli and circumstances Bypassing of cortico-hippocampal route by amygdala Events and sensation burned into neural circuitry No integration into semantic memory -- PTSD Cortex
Clinical Intervention Accelerated Resolution Therapy (ART ) is an exposure-based therapy that incorporates rapid eye movements in a standardized administration over 1-5 sessions. ART is effective brief treatment for PTSD symptoms; but, it s range of therapeutic benefit when applied to people with comorbid HIV infections is not established
Patient does not need to verbalize trauma No homework or medication ART Protocol Three major evidence-based components: 1) Imaginal Exposure (IE) (E. B. Foa et al., 1999; E.B. Foa, Rothbaum, Riggs, & Murdock, 1991). Recall (verbally or non-verbally) details of the traumatic event (scene) while focusing attention on physiological sensations, thoughts, and emotions. 2) Imagery Rescripting (IR) (Hackman, 2011) Imagine changing (replacing) the traumatic scene (imagery and sensory components) from negative to positive (like the director of a movie). 3) Use of Eye Movements (Purves, Augustine, & Fitzpatrick, 2001) Participant follows therapists hand back and forth moving their eyes from left to right, with 40 bilateral eye movements performed per set used in both the IE and IR components.
Mean of 3.5 ART Sessions
Self-Report Changes in Symptoms Before and After Treatment with ART Pre-Treatment Versus 2-Month Follow-Up Symptom Measure N Pre a 2-Mo. a Diff ab ES P PTSD Checklist (PCL-C) 52 54.1 (12.2) 29.5 (12.0) 24.5 (12.2) 2.01 <0.0001 Brief Symptom Inventory 52 30.1 (14.2) 9.6 (11.9) 20.5 (13.3) 1.54 <0.0001 CES-D (Depression) 51 29.0 (10.7) 13.3 (12.1) 15.5 (11.0) 1.41 <0.0001 Pittsburgh Sleep Quality 47 9.8 (4.6) 6.2 (4.2) 3.6 (4.0) 0.89 <0.0001 Trauma Related Growth Global Guilt 52 4.6 (2.4) 1.9 (2.0) 2.7 (2.8) 0.98 <0.0001 Distress 52 18.7 (4.0) 8.0 (5.9) 10.7 (5.6) 1.89 <0.0001 Guilt Cognition 52 44.3 (18.3) 24.4 (14.9) 19.9 (19.2) 1.04 <0.0001 Self-Compassion Scale 52 67.2 (16.8) 82.0 (21.1) 14.8 (17.8) 0.83 <0.0001 Alcohol Use (AUDIT) 52 3.0 (3.3) 1.8 (2.1) 1.2 (2.2) 0.50 0.0008 a Presented as mean (standard deviation). b All mean differences are coded with positive numbers reflecting improvements in symptoms. ES: effect size.