Trauma and Womens Health

1
Trauma and Womens Health

• Amy House, Ph.D.
• Associate Professor
• Medical College of Georgia

2
Outline

• Section 1
• Trauma and PTSD definitions and epidemiology
• Trauma, PTSD, and health outcomes
• Section 2
• The psychobiology of traumatic stress
• Clinical implications

3

• Trauma and PTSD

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Trauma Defined

• DSM-IV
• When a person experiences, witnesses, or is
  confronted with an event or events that involve
  actual or threatened death or serious injury, or
  a threat to the physical integrity of self or
  others, and
• The persons response involves intense fear,
  helplessness, or horror.

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Examples of Traumatic Events

• Intimate partner violence
• Child abuse
• Sexual assault
• Being a crime victim
• Military combat
• Car accident
• Natural disaster
• Other life threatening event

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Responses to Trauma

• Most people adjust well
• Some are resilient
• Some develop symptoms then recover within 3-6
  months
• Partial PTSD
• PTSD

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Prototypical Responses

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Stress Reaction Symptoms

• PHYSICAL
• Fatigue
• Nausea/vomiting
• Muscle tremors
• Chest pain
• Shortness of breath
• Increased blood pressure

• Increased heart rate
• Headaches
• Grinding teeth
• Dizziness
• Chills
• Fainting

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Stress Reaction Symptoms

• COGNITIVE
• Confusion
• Poor attention/concentration
• Difficulty making decisions/poor decisions
• Memory problems
• Loss of time, place, person orientation
• Nightmares
• Intrusive images

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Stress Reaction Symptoms

• EMOTIONAL
• Anxiety
• Guilt
• Grief
• Denial
• Fear
• Depression
• Agitation
• Anger
• Feeling overwhelmed

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Stress Reaction Symptoms

• BEHAVIORAL
• Change in activity level
• Withdrawal
• Outbursts
• Change in appetite
• Restlessness
• Disturbed sleep
• Jumpiness
• Change in speech patterns

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Posttraumatic Stress Disorder

• A. Traumatic event
• (one month ago or more)
• B. Re-experiencing of the event (1)
• C. Avoidance of reminders and numbing (3)
• D. Increased arousal symptoms (2)
• E. Duration of sx at least one month

Note Numbers in parentheses represent the number
of symptoms needed in that category to meet
diagnosis.
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Lifetime Prevalence of DSM-III-RMajor
Psychiatric DisordersNCS Data
Mood Disorders Major depressive
episode 17.1 Dysthymia 6.4 Manic
episode 1.6 Anxiety Disorders Social
phobia 13.3 Simple phobia 11.3 PTSD 7.8 Agoraphobi
a without panic 5.3 GAD 5.1 Panic
disorder 3.5 Substance Use Disorders Alcohol
abuse/dependence 23.5 Drug abuse/dependence 11.9

Adapted from Kessler et al. Arch Gen Psychiatry.
199451819. Kessler et al. Arch Gen Psychiatry.
19955210481060.
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PTSD Risks of Specific Traumas in the US
Population
Percentage
N/A
Natural Disaster
Rape
Combat
Criminal Assault
About 30 of people exposed to trauma developed
PTSD
Kessler RC et al. Arch Gen Psychiatry.
19955210481060.
15
PTSD Rates Related to Specific Traumas
Percentage
Natural Disaster
Rape
Combat
Criminal Assault
Kessler RC et al. Arch Gen Psychiatry.
19955210481060.
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What makes it traumatic? Characteristics of the
Event

• Human-made events vs. natural disasters
• Malicious intent vs. accidents
• Perpetrator is known vs. a stranger
• Event is unexpected vs. expected
• Duration and intensity of event
• Amount of physical violation
• Amount of destruction and loss

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Characteristics of Vulnerable People

• Those who perceive a greater threat
• Those who experience panic or dissociation during
  the event
• Children, elderly
• Lacking in psychosocial resources
• Poor pre-existing psychological health
• Previous traumatic experiences

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• Trauma, PTSD, and Health

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Case Example Lynn

• 35 y.o. white female, married, 2 children
• Obese, Type II Diabetes
• Fatty liver, elevated liver enzymes
• Hx of hyperthyroidism thyroid surgery,
  currently hypothyroid controlled with medication
• Hx of appendectomy
• Gallbladder disease and removal
• Hx of hysterectomy secondary to fibroid tumors
• Hx of pregnancy loss at 6 mos gestation
• Unexplained symptoms that interfere with her
  functioning
• muscle cramps gradually worsening in severity
  over many years, tried on multiple medications
  without benefit
• Severe, chronic childhood sexual abuse, chronic
  depression, chronic PTSD

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Case Example Mary

• 40 y.o. African American female, married, 2
  children
• Hypertension
• Migraine headaches
• Hypothyroidism
• Breast cancer
• Aggressive tumor
• Hx of severe, chronic childhood physical and
  sexual abuse, chronic depression, chronic PTSD,
  severe dissociative symptoms

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Case Example Tonya

• 35 y.o. African American female, separated, 2
  children
• Polycystic kidney disease
• Chronic pain
• Fibromyalgia
• Hypertension
• Asthma allergic rhinitis
• Multiple episodes of childhood sexual abuse,
  recurrent major depression, chronic PTSD

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Trauma Self-Reported Health

• Trauma exposure linked to self-reports of
  impaired physical health in representative U.S.
  sample.
• Lower ratings of global health
• More physical symptoms
• Greater numbers of chronic health conditions
• True even when controlling for demographics,
  psychiatric history, and other stressful life
  events

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Trauma Self-Reported Health

• Adverse Childhood Experiences Study
• 9500 adult HMO patients.
• Pts surveyed regarding adverse childhood events
  abuse, exposure to parental violence, living in a
  household where a family member was a substance
  abuser, mentally ill, suicidal, or imprisoned.
• Compared to those without adverse events, those
  who reported 4 or more adverse events were more
  likely to also report
• chronic bronchitis or emphysema
• stroke
• cancer
• ischemic heart disease
• skeletal fractures
• hepatitis

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Trauma Self-Reported Health

• 239 female pts in a gastroenterology clinic with
  GI disorders
• 65.5 reported some type of sexual and/or
  physical abuse in lifetime
• Those with sexual abuse hx reported more
• Pain
• Non-GI somatic sx
• Bed disability days
• Lifetime surgeries
• Functional disability
• Psychological distress
• Invasiveness/severity of sexual and physical
  abuse predicted worse health outcomes

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Trauma Objective Health Indicators

• 1225 female HMO patients
• Women with hx of child maltreatment evidenced
• greater numbers of medically documented
  psychiatric AND non-psychiatric diagnoses in the
  past year including
• minor infectious disease
• pain disorders
• hypertension
• diabetes
• asthma
• allergy
• abnormal uterine bleeding
• 2x the emergency room visits

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Trauma Objective Health Indicators

• 2005 women enrolled in a multi-site metropolitan
  HMO who reported intimate partner violence within
  the past eight years.
• Abused women had 50 to 70 more gynecological,
  central nervous system, and stress-related
  problems compared to women not experiencing
  intimate partner violence.

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Trauma Objective Health Indicators

• Women with advanced HIV had significantly more
  trauma exposure than a demographically matched
  comparison group from the same community.
• Extent of trauma associated with
• physical symptoms
• poorer functional status
• faster rate of disease progression

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Trauma Disease Progression

• Recent study by Rose, R.C., Pereira, D.B.,
  Antoni, M.H. (2006)
• Having had trauma increased the HIV HPV womans
  odds 35 times of having their SIL stay the same
  or become worse
• Also, if the woman was in a cognitive-behavioral
  stress management group, this decreased their
  odds significantly of progression or persistence
  of SIL compared to women who were not in the group

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Trauma Mortality

• 10-yr follow up of 1567 men and women exposed to
  war-related stressors in Lebanon
• increased of stressors ---gt increased risk for
  cardiovascular disease specific deaths and
  all-cause mortality
• At particular risk
• Women who experienced loss-related trauma
• Women and men who were displaced

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Trauma Mortality

• Vietnam Experience Study
• Compared 4600 women Vietnam veterans with 5300
  women veterans who served elsewhere
• All-cause mortality rates did not differ
• Vietnam veterans had twice the risk for mortality
  from cancers of the pancreas and uterine corpus

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Sexual Abuse/Assault Health

• Sexual abuse/assault related to
• 2x the risk of reporting GI complaints (abdominal
  pain, nausea, diarrhea, constipation)
• 2x the risk of reporting pelvic pain and vaginal
  discharge
• 2x the risk of painful intercourse
• 3x the risk of lack of sexual pleasure
• Increased risk of painful menstruation
• 2x the risk for recurrent headache
• Increased risk of shortness of breath, chest
  pain, dizziness
• 1.4x the risk of ischemic heart disease

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• Does PTSD account for the link between trauma and
  health outcomes?

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PTSD as a Mediator

• A mediator is a variable that explains the
  relationship between two other variables.
• For example
• Cholesterol levels mediate the relationship
  between the amount of fried chicken eaten and the
  degree of coronary artery disease.

Cholesterol
Fried Chicken
CAD
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PTSD Self-Reported Health

• Men and women Vietnam veterans with PTSD
• report a greater number of chronic health
  conditions and have poorer perceived health
  (Kulka et al., 1990)
• increased reports of a number of chronic
  disorders across systems
• True even when controlling for intelligence,
  race, region of birth, enlistment status, army
  medical profile, hypochondriasis, age, smoking,
  substance abuse, education, and income.
  (Boscarino, 1997)

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PTSD Objective Health Indicators

• Vietnam veterans study PTSD associated with
• EEG abnormalities
• Atrioventricular defects
• Infarctions
• True even when controlling for age, ethnicity,
  education, location of service, medications, drug
  alcohol use, body mass index, and cigarette
  smoking.

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Function and Quality of Life In Vietnam
Veterans With and Without PTSD
Percent
Not Working
PhysicalLimitation
ReducedWell-Being
Fair orPoorHealth
Violent BehaviorPast Year
Zatzick DF et al. Am J Psychiatry.
199715416901695.
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PTSD as a Mediator

• Studies of female Vietnam veterans
• PTSD completely or mostly mediated the
  relationship between trauma exposure and health
  status (Friedman Schnurr, 1995 Kimerling,
  Clum, Wolfe, 2000)
• Female sexual assault victims
• Depression and PTSD completely accounted for the
  relationship between traumatic exposure and
  health perceptions (Clum, Calhoun, Kimerling,
  2000)

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PTSD as a Mediator

• Multisite study of 502 primary care patients with
  anxiety disorders
• 46 had trauma histories
• 37 met full criteria for PTSD
• Those with PTSD had more medical conditions than
  those with other anxiety disorders.
• PTSD was a stronger predictor of medical problems
  than
• trauma history, physical injury, lifestyle
  factors, or depression

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What about other psychological symptoms?

• Female veterans with PTSD
• Women with PTSD (n 4348) had more medical
  conditions and worse physical health status than
  women with depression alone (n 7580) or neither
  (n 18,937) (Frayne, Seaver, et al., 2004)
• Rape victims with chronic PTSD (Zoellner,
  Goodwin, Foa, 2000)
• PTSD severity predicted self-reported physical
  symptoms
• True even when controlling for anger, depression,
  and other negative life events
• Sexual assault victims (Clum, Calhoun,
  Kimerling, 2000)
• Both depression and PTSD contributed uniquely to
  explaining global health perceptions and physical
  symptom reports

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What about other psychological symptoms?

• Summary of findings
• PTSD continues to predict health outcomes when
  anger, depression, and other psychiatric
  disorders are controlled for
• However, the effect is reduced
• Depression also plays a unique role

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• How Traumatic Stress
• Impacts Health
• The Psychobiology of PTSD

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The Allostatic Load Model

• Allostasis the bodys ability to achieve
  stability through change
• Allostatic systems
• Autonomic nervous system
• Hypothalamic-pituitary-adrenal (HPA) axis
• Cardiovascular system
• Immune system
• Metabolic system
• In contrast to homeostatic systems
• Body temperature, blood oxygen, etc.

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The Allostatic Load Model

• Allostatic load the cumulative cost to the
  organism (i.e., wear and tear) that results from
  repeated accommodations to stress (underactivity
  or overactivity of allostatic systems)

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Human Stress Response

• Hypothalamic-pituitary-adrenal (HPA) axis
• Locus ceruleus/norepinephrine-sympathetic system
  (LC/NE system)
• Corticotropin releasing factor (CRF)
• The ignition switch for both

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Normal HPA Axis
Hypothalamus secretes CRF
Pituitary Gland releases ACTH
If not
Adrenal Gland releases cortisol and other
glucocorticoids
If sufficient numbers of receptors are occupied,
CRF secretion is inhibited
Hypothalamus monitors circulating cortisol
through glucocorticoid receptors
46
LC/NE System

• Includes adrenergic mechanisms in the CNS and SNS
• The classic fight or flight stress response
• Catecholamines norepinephrine and epinephrine

47
Human Stress Response

• Effectiveness of the stress response
• Ability to mobilize systems
• Ability to return quickly to baseline
• When recovery is not achieved ?
• Chronic stress syndrome

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Chronic Stress Syndrome

• Persistent elevation in CRF secretion?
• Increased HPA axis activation
• Higher ACTH and cortisol levels
• Increased LC/NE activation
• Increased adrenergic reactivity
• Increased catecholamine levels
• Increased endogenous opioids
• Thyroid decreased TSH T3
• Reduction in the activity of
• Reproductive system (GnRH, LH, FSH)
• Growth mechanisms (GH, Growth factors)
• Immunologic system (immunosupression,
  increased inflammatory cytokines)
• Metabolic Syndrome X

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• Does PTSD impact health the same way chronic
  stress does?
• Often, but not always

50
PTSD the HPA Axis

• CSA survivors ?
• Those with PTSD have elevated CRF levels
  enhanced hypothalamic release of CRF vs. without
  PTSD (Yehuda et al., 1996)
• Urinary cortisol levels
• Elevated among women with PTSD (Rasmussen
  Friedman, 2002)
• Decreased among male combat veterans
• May reflect gender, methodological, or
  tonic/phasic differences
• Glucocorticoid receptors may be super sensitive
  (Yehuda, 1999)
• Low cortisol, but increased HPA activity
• PTSD ? hippocampal atrophy

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PTSD the SNS

• Men and women with PTSD (compared to
  trauma-exposed non-PTSD controls)
• Markedly greater SNS responses to threatening
  stimuli
• Blood pressure
• Heart rate
• Skin conductance
• EMG responses
• Slower return to baseline
• Higher resting heart rate and blood pressure

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PTSD THE LC/NE System

• Catecholamine levels
• Elevated baseline levels
• Hyperreactivity in challenge studies
• Contributes to the reexperiencing and
  hyperarousal symptoms of PTSD
• Lower baseline Neuropeptide Y (NPY)
• Blunted NPY response in challenge studies
• Gender considerations
• In healthy subjects Men higher levels of
  catecholamines in response to stress than women
• Women have increased SNS responses in luteal
  phase of menstrual cycle
• Oral contraceptives reduce stress response
• Testosterone increases NPY
• Women have relative decreases in NPY during
  luteal phase of menstrual cycle

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PTSD Brain Function

• Women with hx of CSA PET scans while listening
  to traumatic scripts
• Compared women with PTSD to those without PTSD
• PTSD associated with deactivation of the medial
  prefrontal cortex, hippocampus, and visual
  cortex, and activation of the posterior cingulate
  and motor cortex.

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PTSD Thyroid Function

• Elevated T3 and T4 in combat veterans
• Associated with PTSD severity
• Elevated T3 in female CSA survivors with PTSD

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PTSD the Immune System

• Acute stress enhances immune response chronic
  stress suppresses immune response
• Traumatic stress research results are mixed
• Of 15 studies of immune functioning and trauma
• 8 showed enhanced immunological functioning
• 5 showed immunosuppression
• 2 showed both types of changes
• Explanations?
• Timing of the stressor and the measurement
• Different subgroups recovery vs. PTSD

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Trauma, PTSD, Health
Personal, Social, Cultural Factors
Attentional Processes e.g., altered symptom
perception, mislabeling
Illness Behavior e.g., symptom reports,
utilization, functional status
Psychological Alterations e.g., depression,
anxiety, hostility, poor coping, dissociation
PTSD
Health Risk Behaviors e.g., substance abuse,
smoking, poor self-care
Biological Alterations e.g., HPA axis,
noradrenergic function, immune function
Morbidity Mortality
Trauma Exposure
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• Clinical Implications

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Should you screen for trauma and PTSD?

• The AMA recommends routine screening of women for
  interpersonal violence victimization.
• However, few physicians do so.
• Barriers
• Lack of comfort
• Fear of offending patients
• Sense of futility
• Time constraints
• Most women believe healthcare providers should
  screen for abuse.
• Most are reluctant to disclose violence if
  physicians do not address the issue as part of
  their health care.

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When to screen for trauma abuse

• When the patient has any of these
• Numerous painful chronic health symptoms
• Psychiatric symptoms consistent with PTSD, panic,
  depression, or dissociation
• Difficulty establishing trust
• Feelings of helplessness and shame
• Extreme difficulty with medical procedures
• When you have
• Established rapport
• Reason to think the information will improve
  patient care
• Access to psychological referral sources

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How to screen for trauma abuse

• Start with general inquiry questions and become
  more specific.
• Normalizing introductory statements are helpful.
  EX
• Trauma and abuse are very common in womens
  lives, and can have an important impact on
  health, so Ive begun to ask about it routinely.
• Ask behaviorally specific questions
• Do Have you had anyone touch you sexually when
  you did not want them to?
• Dont Have you been sexually abused?

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• Does psychological treatment help?

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Psychotherapy for PTSD

• Cognitive-behavioral approaches, especially
  exposure therapy, have the most research support
  for their efficacy in reducing PTSD symptoms.
• More effective than supportive therapy
• Often more effective than medications
• No research on whether psychotherapy for PTSD
  improves physical health

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Intriguing possibilities

• Emotional disclosure studies
• Writing about ones worst trauma
• Studied in students and those with chronic
  medical illness
• Has positive health effects
• Reduced depression, pain, physical symptoms,
  number of health center visits
• Improved physical functioning

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Intriguing possibilities

• Large literature showing that CBT reduces pain
  and disability among patients with chronic pain
  conditions.
• Cognitive-behavioral stress management (CBSM)
  improves immune response and reduces cortisol
  levels among breast cancer patients (McGregor et
  al., 2004 Cruess et al., 2000).
• Recent research shows benefits of CBSM in
  HIVHPV women with trauma histories (Rose et
  al., 2006).

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Intriguing possibilities

• Rape/sexual abuse survivors with IBS show marked
  improvement in symptoms after treatment with
  psychotherapy or paroxetine (Creed et al., 2005).
• What we dont know
• Does exposure therapy improve pain and other
  physical symptoms in traumatized patients with
  PTSD?