Post-Traumatic Stress Disorder (PTSD) Among People Living with HIV Milton L. Wainberg, M.D. Associate Clinical Professor of Psychiatry College of Physicians and Surgeons Columbia University mlw35@columbia.edu June 5, 2013 www.hivguidelines.org Stress Pathways 1
Biological findings Neurobiological changes occur at the time of the event. Sensitization of the hypothalamic pituitary adrenal axis (HPA) with paradoxical decrease in cortisol release. Foa, E. B. et al. Symptomatology and Psychopathology of Mental health Problems After Disaster. Journ of Clin Psych (2006) 67:15-25. Yehuda, R. (2001) Biology of Posttraumatic Stress Disorder. Journal of Clinical Psych 62(17):41-46. Acute Stress Disorder Similar to PTSD, but occurs within one month of stressor, and lasts four weeks or less Dissociative symptoms are prominent Adjustment Disorder A category that can be used for less severe stressors People who are experiencing emotional and behavioral symptoms after a stressor, but do not meet criteria for PTSD, ASD or mood disorders. 2
PTSD Prevalence Lifetime community prevalence of 8% of adult U.S. population; 12% in women Highest rates found with interpersonal violence: Survivors of rape (especially when under 16 y.o.) Military combat and captivity Genocide Studies of rates of PTSD among HIV+ people vary from 5% to 74% Varies with the population studied The highest rate was recorded among female prisoners PTSD and HIV are known to be high among sex workers 62% of HIV positive adults endorse traumatic experiences 30% of women LWHA meet criteria for PTSD Machtinger, E. L; Wilson, T. C; Haberer, J. E; Weiss, D. S. (2012) AIDS and Behavior. Vol.16(8). PTSD in Response to an HIV Diagnosis PTSD may occur after a person receives an HIV diagnosis, but: The HIV diagnosis in usually not the exclusive reason This tends to occur in the context of an already traumatic lives Diagnosis, treatment and physical symptoms associated with a life-threatening illness can sometimes be a traumatic event in itself Theunick, A. et al (2010) 3
For African American men, perceived discrimination may mediate the relationship between PTSD and poor treatment adherence. PTSD Perceived Discrimination Poor Treatment Adherence Wagner, Glenn J; Bogart, Laura M; Galvan, Frank H; Banks, Denedria; Klein, David J. (2012) Journal of Behavioral Medicine. Vol.35(1), Feb 2012, pp. 8-18. DSM-5 Just Released PTSD Revisions PTSD (as well as Acute Stress Disorder) moved from the class of anxiety disorders into a new class of "trauma and stressor-related disorders." All of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion. The necessary criteria of exposure to trauma links the conditions included in this class The homogeneous expression of anxiety- or fear-based symptoms, anhedonic and dysphoric symptoms, externalizing anger or aggressive symptoms, dissociative symptoms, or some combination of those listed differentiates the diagnoses within the class American Psychiatric Association, 2013. Diagnostic and statistical manual of mental disorders. (5th ed.). Washington, DC 4
Diagnostic Criteria for PTSD-309.81 A. Exposure to a traumatic event in which: The person experienced, witnessed or was confronted with an event that involved actual or threatened death, serious injury or threat to the physical integrity of self or others Death encounter The person s response involved intense fear, helplessness or horror In children disorganized / agitated behaviors B. The traumatic event is persistently re-experienced in one of the following ways (Intrusion): Recurrent and intrusive recollections Recurrent, distressing dreams nightmares Reliving the event (flashbacks, hallucinations) Intense psychological distress upon exposure to internal or external cues Physiologic reactivity upon exposure C. Persistent avoidance of stimuli associated with the trauma as indicated by 3 of the following: PTSD Diagnosis cont d Avoid thoughts, feelings, conversations Avoid activities, places or people Inability to recall important aspects of the trauma Feelings of detachment, estrangement from others Restricted range of affect (loving feelings) Sense of foreshortened future Diminished interest or participation in important events D. Negative alterations in cognitions and mood: persistent and distorted blame of self or others; and, persistent negative emotional state E. Alterations in arousal and reactivity: reckless or destructive behavior As indicated by 2 of the following: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hyper vigilance Exaggerated startle response 5
PTSD Diagnosis cont d Duration of the symptoms is more than 1 month Disturbance causes clinically significant distress or impairment is social, occupational or other important areas of functioning A clinical subtype "with dissociative symptoms" was added. The dissociateive subtype is applicable to individuals who meet the criteria for PTSD and experience additional depersonalization and derealization symptoms Primary Care PTSD Screen In your life, have you ever had any experience (exposure criterion) that was so frightening, horrible, or upsetting that, in the past month, you 1. Have had nightmares about it or thought about it when you did not want to? (reexperiencing) YES NO 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? (avoidance) YES NO 3. Were constantly on guard, watchful, or easily startled? (arousal) YES NO 4. Felt numb or detached from others, activities, or your surroundings? (avoidance) YES NO Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three (3) items. 6
Co-morbidity Increased rates of: Depression Alcohol/Substance Use Disorders Other Anxiety Disorders Bipolar Disorder Personality Disorders Women exposed to trauma have increased risk for alcohol disorders Women with alcohol disorders have increased histories of sexual abuse PTSD and Alcohol Use Men and women with histories of sexual abuse have higher rates of alcoholism and substance use than those who have not Alcohol worsens PTSD symptoms Emotional numbing Social isolation Anger and irritability Depression Hypervigilence VA National Center for PTSD 7
PTSD and Tobacco Use Smokers are twice as likely as non-smokers to suffer from PTSD* Rates of smoking among people with HIV infection are 2-3 times higher than the general population. Smoking is responsible for considerable morbidity and mortality among people with HIV. *Koenen et al., Arch Gen Psych, 2005 Impact of PTSD on Adherence 6 studies of PTSD and adherence among HIV+ people have been conducted 3 studies found lower adherence 2 studies found higher adherence 1 study found no association Sherr, et. al., Psychology Health & Medicine, 2011 8
Impact of PTSD on Course of HIV Disease Not enough is known because there are few studies examining how PTSD affects the course of HIV disease The common PTSD co-morbidities of depression and alcohol/substance use disorders are associated with worse HIV outcomes and need to be treated PTSD is associated with more unexplainable pain and more HIV physical symptoms Treatment of PTSD Among HIV+ People Few good studies have been conducted A coping group intervention (cognitive appraisal and coping) was shown to be effective; a support group control did not improve (compared to waitlist) For now we need to rely on general studies for treating PTSD 9
Treatment of PTSD Psychotherapy: Strongest evidence for exposure techniques Anxiety management effective Medication: Antidepressants in general Sertraline and paroxetine have FDA approved indications for PTSD Avoid long term use of benzodiazepines Treatment of PTSD-Associated Co- Morbidities Bear in mind: Antidepressants are effective for PTSD as well as other anxiety disorders and depression. But antidepressants alone are not effective for bipolar disorder and may precipitate mania. Personality disorders can be difficult to assess in people with untreated major mental illnesses. Alcohol and substance use disorders need their own separate treatment. 10
Points to Keep in Mind about PTSD and the Therapeutic Alliance Patients with PTSD often have trust problems Meet the patient where s/he is and work from there to meet mutually agreed upon goals. Show continued interest and concern 11