Posttraumatic Stress Disorder: Posttraumatic Stress Disorder: Strategies for HIV PatientsStrategies for HIV Patients

Cheryl Gore-Felton, Ph.D. Cheryl Gore-Felton, Ph.D.

11Stanford University School of MedicineStanford University School of MedicineDepartment of Psychiatry & Behavioral SciencesDepartment of Psychiatry & Behavioral Sciences

Stanford, CAStanford, CA

Research supported by NIMH grants MH63643, MH54930A, MH54930 and MH52776

Adults and children estimated to be living Adults and children estimated to be living with HIV as of end 2006with HIV as of end 2006

Total: 39.5 (34 – 47) million

Western & Central Europe

740 000740 000North Africa & Middle

East460 000460 000Sub-Saharan Africa

24.7 million24.7 million

Eastern Europe & Central Asia1.7 million1.7 million

South & South-East Asia 7.8 million7.8 million

Oceania

81 00081 000

North America 1.4 million1.4 million

Caribbean250 000250 000

Latin America 1.7 million1.7 million

East Asia750 000750 000

HIV Transmission

Globally, the majority of AIDS cases result from either unprotected sexual intercourse or the use of contaminated injection drug needles.

Both means of transmission can be prevented through behavioral change.

Sexual Risk among HIV-Positive AdultsSexual Risk among HIV-Positive Adults

Once individuals learn their HIV-positive serostatus, most change their behavior to avoid transmitting the virus (Crepaz & Marks, 2002; Kalichman et al., 2000).

A review of the research on risk behavior among HIV-positive adults suggests that high-risk behaviors are more likely with other infected persons, but significant rates of risk behaviors are observed with HIV-negative partners and partners of unknown serostatus (Kalichman, 2000).

As a result, it is important to understand factors associated with high-risk sexual risk behavior particularly among HIV-positive individuals..

Posttraumatic Stress DisorderPosttraumatic Stress Disorder

Criterion A1: Criterion A1: – Exposure to extreme traumatic stressor Exposure to extreme traumatic stressor

involving direct personal experience of actual involving direct personal experience of actual or threatened death or serious injury, or other or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing threat to one’s physical integrity; or witnessing these events; or learning about unexpected or these events; or learning about unexpected or violent death, serious harm, or threat of death violent death, serious harm, or threat of death by a family member or close associate.by a family member or close associate.

PTSD criteria from DSM-IV-TR (2000)

Posttraumatic Stress DisorderPosttraumatic Stress Disorder

Criterion A2Criterion A2– Response to traumatic event or experience Response to traumatic event or experience

must involve intense fear, helplessness, or must involve intense fear, helplessness, or horror [ in children the response must involve horror [ in children the response must involve disorganized or agitated behavior]disorganized or agitated behavior]

Hallmark Symptoms of PTSDHallmark Symptoms of PTSD

Reexperiencing (1+)Reexperiencing (1+): intrusive thoughts, night terrors, : intrusive thoughts, night terrors, flashbacks, physiological reactivity (heart rate, blood flashbacks, physiological reactivity (heart rate, blood pressure);pressure);

Avoidance (3+)Avoidance (3+): avoid places, persons, things that : avoid places, persons, things that remind individual of trauma; diminished responsiveness remind individual of trauma; diminished responsiveness (numbing); feelings of detachment, reduced ability to feel (numbing); feelings of detachment, reduced ability to feel emotions (intimacy, tenderness, sexuality), sense of emotions (intimacy, tenderness, sexuality), sense of foreshortened future;foreshortened future;

Hyperarousal (2+)Hyperarousal (2+): difficulty falling or staying asleep, : difficulty falling or staying asleep, hypervigilance, exaggerated startle, irritability, outbursts hypervigilance, exaggerated startle, irritability, outbursts of anger, difficulty concentrating.of anger, difficulty concentrating.

Symptom DurationSymptom Duration

Reexperiencing, avoidance, and hyperarousal Reexperiencing, avoidance, and hyperarousal symptoms must occur for more than one month.symptoms must occur for more than one month.

The symptom disturbance must cause clinically The symptom disturbance must cause clinically significant distress or impairment in social, significant distress or impairment in social, occupational, or other important areas of occupational, or other important areas of functioning (interpersonal).functioning (interpersonal).

Acute PTSD if symptom duration < 3mosAcute PTSD if symptom duration < 3mos

Chronic PTSD if symptom duration >=3mosChronic PTSD if symptom duration >=3mos

Trauma & HIV

In comparison to the general population, people living with HIV tend to report experiencing more traumatic life events, particularly those that are violent and abusive.

There is a strong relationship between previous trauma and subsequent HIV infection.

Implications for Clinical Practice

Strong association between trauma experiences and Strong association between trauma experiences and development of:development of:

– Posttraumatic Stress Disorder (PTSD) & Posttraumatic Stress Disorder (PTSD) & other other Anxiety DisordersAnxiety Disorders

– Alcohol and Substance DisordersAlcohol and Substance Disorders

– Depressive DisordersDepressive Disorders

Case Example: Mr. SMr. SMr. S

– 38 year old gay-identified Caucasian male diagnosed with 38 year old gay-identified Caucasian male diagnosed with HIV in 1992. His viral load had been undetectable for the HIV in 1992. His viral load had been undetectable for the past 6 years. past 6 years.

– Overall, Mr. S is in good health. He has a history of being Overall, Mr. S is in good health. He has a history of being victimized because of his sexual orientation, and on one victimized because of his sexual orientation, and on one occasion he was beaten so bad that he suffered three occasion he was beaten so bad that he suffered three fractured ribs. fractured ribs.

– He admits that he has a tendency of getting involved with He admits that he has a tendency of getting involved with partners who have “tempers.” For the past 5 years, he has partners who have “tempers.” For the past 5 years, he has been in a relationship with a male partner who has been been in a relationship with a male partner who has been violent toward him. violent toward him.

Note: key demographic and relationship variables have been manipulated to mask identity

Case Example: Mr. S

During elementary and junior high school, Mr. S suffered insults, derogatory epithets, and physical bullying (e.g., pushing, being spat on, hit) on an almost daily basis.

He never told anyone about the abuse.

By the time he graduated high school he was a fixture at the gay bars. During high school he began to date older men and around that time he was involved in his first abusive relationship with another man.

Childhood Trauma & Adult Risk

Risk behavior often develops in response to traumatic experiences.

When physical and emotional abuse occurs during childhood, the sense of oneself is challenged and the emotional response can be overwhelming.

Individuals will seek homeostasis by engaging in behaviors to numb the negative feelings.

In the case of Mr. S, he used alcohol and sex to numb his emotional pain. He thought he was to blame for the abuse he suffered and as his punishment he continued to expose himself to risky situations that included abusive relationships.

Initial Therapeutic Focus

Therapy focused on working through negative affect and trauma-related symptoms (i.e., avoidance behaviors, emotional numbing) associated with his abuse experiences.

Focusing his attention on his negative feelings about his sexual orientation in a safe, nonjudgmental environment enabled him to realize that he had been reacting to others’ hatred which was separate from how he felt about himself.

Initial Therapeutic Focus Continued

Through this process he was able to articulate his desire to meet a man and establish a long-term relationship.

Prior to therapy, Mr. S could not articulate this desire and engaged in behaviors such as one-night stands, excessive alcohol use, and abusive partners that ensured that he would not establish a long-term, loving relationship with another man.

Successes and Challenges Successes and Challenges of Initial Clinical Focusof Initial Clinical Focus

Mr. S began romantic relationship, and initially engaged in protected sex with partner.

As the relationship deepened in intimacy, the couple desired more intimate contact and condom use decreased. This caused Mr. S distress because he was concerned about infecting his partner who was not HIV-positive. This stress exacerbated his PTSD symptoms (emotional distancing, isolation, outbursts of anger, difficulty sleeping, increase in alcohol use).

Intermediate & Long-term Clinical FocusIntermediate & Long-term Clinical Focus

Over time, there tends to be a natural evolution for sexual relationships to deepen sexual intimacy through skin to skin contact, which is part of the human experience for most individuals.

Assisting couples to understand this normal desire and not pathologize it is an important aspect of interventions to reduce risk behavior.

Intermediate & Long-term Clinical FocusIntermediate & Long-term Clinical Focus

Effective therapists need to have genuine empathy for couples who are struggling with these basic human needs so that viable alternatives are explored and factors that motivate safer behavior within couples can be used to minimize transmission risk.

Maintenance of skills that promote emotion regulation are key to long-term resolution of trauma-related symptoms.

Behavioral FocusBehavioral FocusRegulate sleep (sleep hygiene; Regulate sleep (sleep hygiene; psychopharmacologic agents)psychopharmacologic agents)

Eat regular, balanced mealsEat regular, balanced meals

Maintain adequate hydrationMaintain adequate hydration

Begin or maintain regular physical exercise at Begin or maintain regular physical exercise at least 3 times a weekleast 3 times a week

Diaphragmatic breathingDiaphragmatic breathing

Meditation/Self hypnosis/Relaxation Exercises Meditation/Self hypnosis/Relaxation Exercises (visual Imagery, progressive muscle relaxation)(visual Imagery, progressive muscle relaxation)

Psychosocial FocusPsychosocial FocusReduce Isolation

Identify triggers that result in trauma-related stress responses

Develop skills to cope with triggers and problem solve any challenges that prevent individuals from using adaptive coping strategies

Treat symptoms not the disorder—tailor for individual differences

Conclusions

The lives of HIV-positive persons are often complex, The lives of HIV-positive persons are often complex, and their social as well as psychological needs often and their social as well as psychological needs often go unmet.go unmet.

Maintaining behavior change for many years requires well-developed coping skills and the use of strategies to manage mental health distress symptoms to sustain reductions in transmission acts.

Psychosocial interventions that develop social Psychosocial interventions that develop social support and the ability to learn adaptive coping support and the ability to learn adaptive coping skills have been successful in helping patients skills have been successful in helping patients manage their anxiety and depression.manage their anxiety and depression.