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
MAIN POINTS
 Description of PTSD
 PTSD in the General Population
 PTSD-HIV
 PTSD negatively impacts health of
people with HIV infection
 Diagnostic criteria
 PTSD screening questions
 Co-occurring mental disorders
 Treatment options
MENTAL DISORDERS
INTRODUCTION
GOOD MENTAL HEALTH
“The successful performance of mental
function, resulting in productive activities
fulfilling relationships with other people,
and the ability to adapt to change and to
cope with adversity; from early childhood
until late life, mental health is the
springboard of thinking and
communication skills, learning, emotional
growth, resilience and self esteem.”
HRSA
RISKS FOR MENTAL ILLNESS
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Chronic illnesses, including HIV infection
Early life trauma
Drug and alcohol addiction
Homelessness
Perpetrator or recipient of violent acts
Incarceration / Institutionalization
Poverty
Physical disabilities
Chronic pain
MENTAL ILLNESSES ARE
ASSOCIATED WITH POORER
PHYSICAL HEALTH OUTCOMES
Most studies done in depression (24%
increased risk of death w/in 6 years of
diagnosis)
Int J Psych Med 1994; 24:103-113
Osborn, David P. J. “The Poor Physical Health of People with Mental Illness”. West J Med
175(5):329-332, 2001.
Smith, Michael T. PhD, et. al. “Comparative Meta-Analysis of Pharmacotherapy and Behavior
Therapy for Persistent Insomnia. Am J Psychiatry. 159:5-11, 2001.
Diagnostic Criteria from DSM IV TR
WHAT IS PTSD?
MOOD AND ANXIETY DISORDERS
21% of adult Americans will suffer mood and anxiety disorders during
their lifetimes
PTSD is an anxiety disorder
Mental Health in Adulthood www.surgeongeneral.gov
SPECTRUM OF ANXIETY DISORDERS

PTSD

Adjustment disorder

Obsessive compulsive disorder

Panic disorder

Generalized anxiety disorder
Refer to Diagnostic Criteria DSM IV TR
POSTTRAUMATIC STRESS DISORDER
BASIC CRITERIA
A. Exposure to a traumatic event that threatened
death, serious injury resulting in intense fear,
helplessness, or horror
B. Traumatic event persistently re-experienced
with physiological responses
C. Persistent avoidance of stimuli associated with
the trauma
D. Persistent symptoms of increased arousal
E. Duration of disturbance more than 1 month
F. Clinically significant impairment in social, and
occupational environments, etc.
POST TRAUMATIC STRESS DISORDER
Should be viewed as a treatable condition
Remember it is:
POST
TRAUMATIC
STRESS
DISORDER
=
=
=
=
PAINFUL
TREATABLE
SENSORY
DYSFUNCTION
CASE
Ms. “P” was walking down the street with her
child when a stray bullet hits her child in the chest
and instantly kills the child. Ms. “P” recalls
nothing of the event except that she heard her
child say, “Blood Mommy,” as she fell to the
sidewalk. Ms. “P” was taking her child to school
and from there was to see her HIV doctor. Ms. “P”
had a 10 year relationship with her doctor with no
substance use history or adherence problems.
Previously she had been totally focused on
maintaining good health and being the best
mother possible. She had been a model patient.
CASE Continued
She never made it to the clinic that day and after
multiple failed outreach attempts Ms. “P” was lost
to follow up. She reappeared at clinic almost a
year later when she had self discontinued HAART,
her CD4 was 122 down from 595, viral load was up
(54,000) after being undetectable for 5 years. At
several appointments she merely told her MD that
her 9 year old daughter had died. He was
empathetic but did not probe, thinking it would
upset her.
CASE Continued
She resumed HAART but missed doses and medical
appointments and fell into the “difficult patient”
category. She denied depression, feeling nervous,
and was not suicidal or homicidal. She did report
nightmares, social isolation, and fear of walking
down certain streets as well as fear of coming to
the clinic. While in the waiting room she frequently
experienced palpitations, jitters, SOB, and would
sometimes leave w/o being seen. The staff dubbed
her “drama queen.”
CASE Continued
In review of the medical record and case discussion
it became clear that there was an abrupt change in
her pattern of keeping appointments and taking her
medication. At a subsequent visit her doctor used
a mental health screening tool and discovered
symptoms of depression and PTSD. A mental
health referral was generated. The outcome is
unclear because Ms. “P” moved to Georgia to be
closer to her family.
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
WHAT is PTSD?


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.
IMAGING STUDIES and PTSD
MRI findings may represent pre-trauma vulnerability
or consequence of traumatic events
 Non-specific white matter lesions
 Decreased hippocampal volume
PET findings
 Increased activation of amygdala 7 anterior
paralimbic structures (emotions)
 Greater deactivation Broca’s area (speech)
Bremner JD, Randall P, et al. Magnetic resonance imaging-based measurement of
hippocampal volume in posttratumatice stress disorder related to childhood physical
and sexual abuse-a preliminary report. Biological Psychiatry Vol 41, Issue 1, Jan 1997
pp 23-32.
PTSD
Key Screening Questions
for the Busy Practitioner
In your life have you ever experienced an event that was
so horrible, upsetting or frightening that you:
Have nightmares about it or think about it when
you don’t want to?
Try hard not to think about it or go out of your way
to avoid situations or places that remind you of it?
Find yourself constantly on guard or easily
startled?
Feel numb or detached from others or your
surroundings?
Are these changes associated with physiological
changes?
COMMONLY CO-OCCURING DISORDERS
Important to screen for co-occurring
psychiatric conditions:
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Depression
Anxiety Disorders
Psychotic disorders
Bipolar disorders
Personality disorders
Immediate harm to self or others
PTSD and the GENERAL POPULATION


50% of adults and children have been
exposed to traumatic events that could lead
to PTSD
12-50% of those exposed to trauma will
develop PTSD
Davidson,J, Bernik, M, et al. “A New Treatment Algorithm for Posttraumatic Stress Disorder”
Psych Annals Nov 2005;35:11: 887-898
PTSD and the GENERAL POPULATION

8% prevalence in general population

Chronic course develops in up to 50%
Davidson,J, Bernik, M, et al. “A New Treatment Algorithm for Posttraumatic Stress Disorder”
Psych Annals Nov 2005;35:11: 887-898
SUBSTANCE USE and PTSD
SUBSTANCE USE

Concurrent substance use disorder in 24-40%
of individuals

Substance abuse worsens course of mental
illness
Mental Health in Adulthood” www.surgeongeneral.gov
COCAINE DEPENDENCE

30-50% meet criteria for lifetime PTSD

Associated with increased rates of exposure
to previous trauma
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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)
OCCUPATIONAL HIV EXPOSURE
and PTSD
OCCUPATIONAL HIV EXPOSURE
AND PTSD

Two healthcare workers developed disabling chronic
PTSD after needle stick exposure (22 months later)

PTSD despite repeatedly negative HIV antibody tests
Worthington, M. G. et al. (2006)”Posttraumatic stress disorder after occupational HIV
exposure: two cases and a literature review.” Infec Con Hosp Epi 27(2):215-217
OCCUPATIONAL HIV EXPOSURE
AND PTSD

Need for evaluation of role for
long term psychological follow
up, counseling and support
Worthington, M. G. et al. (2006)”Posttraumatic stress disorder after occupational HIV
exposure: two cases and a literature review.” Infec Con Hosp Epi 27(2):215-217
CHILDHOOD and PTSD
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
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Chronic depression
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Sexual compulsivity
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Revictimization
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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
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

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
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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

Elevated VL / poor response to HAART

Poor adherence

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

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.
TREAMENT
TREATMENT
PTSD Treatment requires care from
experienced mental health
Professionals.
TREATMENT
Strategies must include treatment for
co-existing mood and anxiety
disorders, alcohol and substance use
disorders.
VA National Center for PTSD
PTSD TREATMENT MODALITIES

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)
PTSD TREATMENT MODALITIES
PHARMACOTHERAPY


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Sertraline and Paroxetine are FDA
approved for treatment of PTSD
Other SSRIs
Topiramate (Topramax) and other
anticonvulsants
TCAs
PTSD TREATMENT MODALITIES
EMDR


(Eye Movement Desensitization and Reprocessing)
Creates similar brain activity as REM
(Rapid Eye Movement) during sleep
REM assists in processing ideas and
resolving conflicts
PTSD TREATMENT MODALITIES

CAUTION ADVISED

Benzodiazepines

Use short term

Close monitoring

Abuse potential

Disinhibition, especially in those with
severe dissociative symptoms
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
TREATMENT GOALS
TREATMENT GOALS


Build trusting patient-clinician
relationships
Optimize health and well being
TREATMENT GOALS

Minimize symptoms

Fully reintegrate a safe sense of self

Improve adherence

Improve CD4 and viral levels
TREATMENT GOALS

Improve integration of care and
communication among providers of
care in order to maximize treatment
success
INTEGRATION OF CARE
HIV
Medical Care
INTEGRATION
OF CARE
Mental Health
Services
Substance Use
Treatment Services
THANK YOU
For more HIV-related resources,
please visit www.hivguidelines.org