PTSD Signs & Adult Health

Foreign. So this presentation is on PTSD and adult health. We're going to explore the comorbidities in adult health with ptsd. So what health conditions might we expect to see in people who've experienced trauma or who have PTSD? The lifetime prevalence of trauma is 60% in men and 51% in women, which we generally expect it to be flip flopped. But that's not what the data says. So the most common forms of trauma resulting in PTSD included unexpected death of someone close, sexual assault, serious illness or injury to self, or someone close, serious car accident, having a child with a serious illness, a terrorist attack or a natural disaster. Let's think about this. Normally when we think of ptsd, we think of something like war trauma or being the victim of a violent crime. But there are a lot of other things that can lead to a sense of helplessness and horror and the threat of serious injury or loss of life. So we do want to consider that these things and we also want to consider the impact of whatever it is and the age of the person impacted. Something like an unexpected death of someone close may pro and probably has a different impact on someone who's 35 as opposed to someone who's 5. So we do want to recognize that brain development, cognitive development and just number of years on this planet and experiences may, may serve to buffer or may actually impair if they've already got traumatic experiences, the reaction, serious car accidents, you know, we want to recognize and for, for some people, there are some studies that I read, you know, when people a heart attack it. Some people who have heart attacks end up developing post traumatic stress because of the severity of the illness, the fact that they almost died, you know, all that sort of thing in complex ptsd. Now this is PTSD that develops as a result of exposure to multiple traumas or repeated traumas over a period of time. Domestic violence, child abuse. And we do see complex PTSD in law enforcement, fire, rescue, military. In complex ptsd, structural abnormalities in the brain seem to be more extensive than in PTSD in which there was a single trauma. And brain activity in complex PTSD is also strikingly different from the brain activity seen in people who experienced a single trauma. So this ongoing exposure, this ongoing lack of safety, this ongoing threat tends to disrupt neural connections and the way the brain actually works in a different way. Remember in the, in the last class we talked about how the amygdala, when it's initially exposed to trauma, increases in size. But over, over a lifetime, over a time span, if exposure to traumatic experiences Stressful experiences continues, then the amygdala actually starts to shrink. So we do see that the brain alters its actual structure as a result of exposure or non exposure to trauma. Let's think about 2021 or 2020, if you will. There seems to be an increase in PTSD related to the pandemic. Seeing people get sick, having people suddenly die, having people that you love have to go in the hospital, not being able to be there with them, and having them pass away by themselves. You know, there were a lot of things that happened in 2020 that were extraordinarily traumatic for a lot of people that were related to the pandemic. So it is important to recognize that. It's also important to recognize how many ACEs occurred because of the pandemic intergenerational PTS. Now, notice I dropped the D off of it. When people experience ptsd, they, and it goes unresolved, they may carry forward some of that hypervigilance. They may carry forward some of those, the negative impressions of themselves and the world. They may carry forward, you know, the PTSD symptoms. Those are communicated to their children. Their children grow up hearing those messages, hearing how the world is an unsafe place and feeling unsafe and afraid, which, you know, can create pts in those children. And those children may grow up and be hypersensitive or hyper vigilant to threat trauma. So intergener generational pts and intergenerational aces are really a thing. So it is important that we advocate for caregivers to make sure that if they're experiencing symptoms, that they have a way to address them. And then the last one, I didn't know what to call it. Cultural pts. There have been a lot of things that have happened in the past five years, maybe even 10 years that have created a lot of trauma for a lot of people in the American culture. And, you know, you, you don't have to go far on social media to find people who are experiencing a lot of distress as a result of things that are going on in the world. So it's important to also recognize that, you know, there is a lot of stuff and media. And social media unfortunately keeps that wound right in your face. I was so grateful when. The news channels decided to take down the, what I called the death counters, because every time I saw those, it just stressed me out and it increased my levels of anxiety. And, you know, that that had to do with the pandemic. But remembering that there is a lot that is out there on, you know, from multiple perspectives, and we need to help people Examine the cultural stress that they may be experiencing and we'll talk about that more in Moral Trauma and moral stress when we get to the, to the last section. People with ptsd, not surprisingly, have higher rates of mood disorders, especially if they have prolonged ptsd. Now that's not necessarily complex ptsd. That's people who've had PTSD for a long time and it's gone untreated. Well, think about it. What are the symptoms of ptsd? Hypervigilance, intrusion, intrusive memories, feelings of unsafeness. You know, basically. Well, if you feel this way a lot, then yeah, it's probably going to contribute to anxiety and depression. That's really not a stretch. There are two types of responses to traumatic reminders of the stressors though there, and they've actually differentiate differentiated two different subtypes of ptsd, which I thought was kind of interesting. DPTSD people tend to over modulate their emotions and, and they tend to distance from their emotions as opposed to patients who primarily suffer from re experiencing symptoms, including hyperarousal, intense feelings of shame and difficulties in emotion downregulation. So DPTSD people tend to be in the more numbing category, whereas the other type of PTSD may have a lot more in common with people with borderline personality symptoms. And, and I put the word symptoms on the end of it because it's. So what's the word I'm looking for? Stigmatized. To be diagnosed with borderline personality disorder, you know, we really want to look at what symptoms does the person, do they have, what function are those symptoms serving right now? Where did they come from and you know, what is going on. A lot of people in addiction recovery, for example, in early recovery, often have a lot of emotional disregulation and dichotomous thinking and you know, a lot of the characteristics of bpd. However, once they have some recovery time under their belt, as we say, a lot of those symptoms seem to remit some once they start to feel safer and feel more empowered in their situation. PTSD is positive related to negative emotionality. Makes sense. Neuroticism, and I don't like the term. That's another one that's gotten a really bad rap in just general language. Neuroticism as we're using it is one of the big five personality characteristics and refers to dysregulation, hypervigilance, or the degree to which a person believes the world is distressing, threatening or unsafe. Well, if you've got ptsd, then yeah, and you're still experiencing those symptoms Then yeah, you're, there's a good chance that these characteristics are going to be present. Harm, avoidance, self transcendence, hostility, anger and anxiety. So as PT that PTSD symptoms go up, these things go up as well. And a lot of these are actually kind of just synonyms for a lot of the PTSD symptoms, in my opinion. But now PTSD symptoms are negatively associated. So as these symptoms go up, PTSD symptoms go down. They're negatively associated with extroversion, the ability, willingness, desire of a person to interact with others, to get social support, conscientiousness, self directedness. So being able to set goals and accomplish them, which helps people develop a sense of empowerment and self efficacy, high positive emotionality. So as PTSD symptoms go down, mood goes up. Go figure it. Hardiness and optimism. Now, hardiness was proposed by Cabasa in 78, I believe, and it's composed of three characteristics. Commitment, control, and challenge. Commitment refers to a person being able to look not at just one aspect, but broadly at their life and say, these are all the things that are important in my life. And I'm committed to all these things. I'm committed to my job, I'm committed to my kids, I'm committed to my pets, I'm committed to my hobbies, you know, and at any point in time, one or more of these things may not be going the best, but I'm committed to all of them. And I recognize that I can have a rich and meaningful life and experience some distress. So there's a commitment and recognition that all your eggs aren't in one basket, so to speak. Control is the belief or awareness of the aspects of situations that you can and cannot control. So someone recovering from a heart attack or open heart surgery. There are a lot of studies done with hardiness and open heart surgery. The ones who were able to view their life and say, okay, well, maybe I can't do this anymore because I had this heart attack, but all of these other things that are important to me, I can still do so, or I can do with modification. And that's important. I'm committed to those things. They recognize control. You know, I can't undo the heart attack. I can't, you know, maybe I can't run a marathon anymore, or whatever it is they did, they recognize that's out of their control. But what's in their control, following their recovery program, taking their medication, eating a healthy diet, you know, all the things they're supposed to do that can allow them to be able to engage with the things that are important that they're committed to. And then C, the final C stands for challenge. Instead of viewing recovery from a heart attack or recovery from PTSD or life in general as an obstacle and overwhelming and, you know, oppressive, viewing it as a challenge, thinking, okay, that's fine, how am I going to do this? Having a more optimistic attitude and a more empowered and efficacious attitude is the third component of hardiness. And I think in cognitive behavioral approaches there are a lot of these things that we can increase in people now. Extroversion, you know, little note on that. People who are normally, you know, temperamentally introverts are not going to want to often be going to big support group meetings and everything. Extroversion for them may mean having one or two people that they're reaching out to and connecting with. So we do want to recognize and be sensitive to individual differences. But we can help people enhance their self directedness, their ability to set goals, their. Self efficacy and, and self esteem, all of those things that we can do. We can help them enhance their level of hardiness. And hardiness is kind of at the core, if you will, of acceptance and commitment therapy. Sleep dysfunction. 70 to 91% of individuals with PTSD report sleep disturbances. That's a lot, especially since we know that sleep disturbances are directly correlated to HPA axis activation, increases in inflammation, difficulties with cognitive functioning, depression and anxiety. So sleep is important. The most common sleep disturbances in PTSD are insomnia, nightmares and, and obstructive sleep apnea. Now this, this is where it gets interesting. Sleep disorders contribute to major depression, substance use, impaired daytime functioning, negative long term health consequences, and suicide risk. We don't want to minimize sleep disorders. Insomnia may precede the trauma and predict the development of ptsd. So people who had insomnia prior to the trauma are at greater risk of traumatic injury of developing PTSD after exposure to a trauma than people who were well rested and did not have insomnia. So that's one of those things that we now know is a risk factor that we can actually ask about. Prior to the trauma, did you have insomnia? Were you sleeping well? SSRIs and SNRI. So selective serotonin and selective norepinephrine reuptake inhibitors, antidepressants are commonly recommended as first line treatments for PTSD. But the effects of SSRIs or SNRIs on sleep are typically modest or even adverse since they disrupt REM sleep. Remember, you have three phases of sleep. You have light sleep where you're easily awakened. You're just dozing. Remember rem where you're dreaming and deep sleep, in which your, your body cleaning crew is going through and clearing out all of the adenosine from your brain and all of as much of the free radicals and everything as it can. Deep sleep is really important, but REM sleep does have a place. Benzodiazepines are not advised because of their risk of tolerance, abuse and worsening of obstructive sleep apnea. Trazodone has been shown to promote sleep and reduce nightmares in PTSD and depressed patients and may be particularly helpful for patients with concurrent ptsd, alcohol use and obstructive sleep apnea. So for some reason, trazodone, which is a serotonin agonist and and reuptake inhibitor, doesn't seem to have the same effects on obstructive sleep apnea as some other medications. CPAP therapy, which is what they use with obstructive sleep apnea, has produced small but consistent decreases in PTSD severity at 12 weeks. CPAP therapy for people with obstructive sleep apnea has been shown to produce so many positive effects, it reduce, it improves mood, reduces depression. It re evidently reduces PTSD symptoms as well. It's also been shown to reduce inflammation and severity of autoimmune symptoms when people are repeated. Remember, with obstructive sleep apnea, people are basically stopping breathing multiple times throughout the night. When you do this, your body's reaction, it says, crap, we're not breathing, we need to breathe. So the HPA axis, that stress response system, kicks into gear and, you know, prompts you to, you know, start breathing again. It's like, hey, wake up. So when people have obstructive sleep apnea, they are contributing to additional stress on that HPA axis. People with PTSD have a much higher rate of autoimmune disorders. Makes sense. If they're not sleeping well, that's going to contribute to inflammation. If they're stressed, that contribute. We know that contributes to inflammation. If we have depression, well, we don't know if that causes inflammation or as a result of inflammation, but we know the two co occur autoimmune disorders. The main diagnostic feature is inflammation. So people with PTSD do have higher rates of autoimmune disorders. They also have higher rates of coronary and, and cardiovascular disease. But it's interesting that it also works in the other direction. About 10 to 20% of people develop PTSD following acute coronary syndrome. So heart attack, mainly PTS symptoms increase the risk of adverse cardiovascular events as a result of Dysregulation of the autonomic nervous system. So all of those things that we normally do automatically, like breathing and heart rate, are dysregulated to a certain extent with ptsd. Disregulation of the hypothalamic pituitary axis, that HPA axis, oxidative stress and inflammation. So PTSD really gets in there and upsets the apple cart, which causes, it doesn't just correlate with. They've shown that it increases the risk significantly of cardiovascular diseases, cardiovascular problems, but because of these physiological effects of stress addiction. And I want you to think about the paradox of trauma processing in substance abuse treatment as, as we go through this. Addiction can be used to self medicate trauma or trauma symptoms. You know, that is the first thing that a lot of us, you know, go to with addiction is something of a self medication hypothesis. Okay, well, that's true. Trauma affects the dopaminergic pathways in ways that largely mimic the effect of addictive drugs, causing increased dopamine release in the nucleus accumbens. I told you we would get to this. So what that's saying, even though in trauma, people are not experiencing euphoria like they do with drugs in trauma, when that HPA axis is activated, our body wants us to be motivated to fight or flee. So there's a dump, along with glutamate, norepinephrine, and adrenaline of dopamine. So it's not as important why the dopamine's dumped, but the fact that a bunch of dopamine is being dumped in the nucleus accumbens. So the same tolerance develops in addiction. You know, and that was the, the analogy I used earlier, because we're dealing, we're talking about the same neurotransmitter here. We're talking about dopamine. And regardless of why it's dumped, whether it's because of a traumatic experience or because of drug use, if the brain is bombarded with too much dopamine for too long, it starts becoming resistant. Another analogy that may make more sense. Sometimes we talk about lock and key, and neurotransmitters are the keys, and your receptors are the locks, the doors. And when there's too much dopamine going through, when the, the locks are constantly being bombarded by the dopamine, eventually the locks stop working. So there are fewer doors, if you will, for the dopamine to go through. And that's kind of the body's way of saying, okay, you know, if we're really tired, we can't have all this going through. But it is interesting. Stress enhances the effects of drug related cues. Well, that makes sense because stress, just like trauma, increases the release of dopamine because we want to be motivated. Stress is kind of the garbage term for fight or flee. HPA axis activation. So stress increases the amount of dopamine that's available, which makes us, makes people more aware of drug related cues. And when people are more aware of drug related cues, then the body says, oh I remember that, that was a good thing. And so they start having increased Q induced cravings, which can lead to reinstatement of drug self administration. So people have a little stress, causes a little bit of dopamine to be in the, in the, in the body. Then that starts to be related to other things that remind them of when they had a whole lot more dopamine and it can lead to cravings. Repeated or prolonged exposure to stress can also recapitulate some of the core pathophysiology of addictions, including sensitization of the dopaminergic response, which is what we've been talking about, having those locks stop working. The, the brain becomes sensitized to the effects of the key, if you will. So there's a paradox here. A lot of people with addiction have trauma and a lot of people with trauma have addiction. Not everybody in either condition. But when you have somebody who has addiction and trauma, we know that trauma mimics the addictive, the dopamine release like when somebody is using. Not to the same extent, obviously. So the question is, do you process trauma in people who are recovering from addiction? And some people might say, well no, if stress is going to enhance their cravings, then processing trauma would add stress. So we don't want to do that. And in actuality that's not correct. If the PTSD symptoms are still existing, if the PTSD is not under control, then the person already has stress. So when they are clean, they are going to have more cravings because of that underlying stress. So we need to help them deal with it, which is why concurrent treatment is so important. But it's also important to recognize if you're working with somebody who is in outpatient, in addiction recovery, that the timing of the processing of these things, how quickly you go, what their emergency plans are, need to be planned out very, very carefully. Because processing trauma can set them up for being vulnerable to relapse. Not to say it shouldn't be done, it needs to be done because ultimately if it doesn't get processed, it often leads to relapse. But it is important to make sure that it is done with care, especially in outpatient settings where the person has access to their drug of choice. Psychiatric disorders that are comorbid with alcohol use disorder, such as ptsd, major depressive disorder and other substance use disorders may also have underlying neuroimmune mechanisms. I thought that was interesting. So neuroimmune mechanisms meaning targeting the immune system and one of the things that they've started to recognize is the cannabinoid 2 receptor or your CB2 receptor is one of the receptors in the endocannabinoid system and it actually is mainly in the immune system. Can CB2 dysfunction is involved in mood disorders? They're not sure exactly how, but they know when the CB2 receptors are not activated enough, it leads to problems, or when they're over activated it also leads to problems. But they're also finding that. Substance use disorders as well as PTSD and, and mood disorders have neuroimmune underpinnings and they're thinking it may have something to do with the CB2 receptor. We do see more abuse of benzodiazepines in people with ptsd. Benzodiazepines are your anti anxiety medications. PTSD people h tend to have anxiety. So it makes sense that that might be a self medicating step that, that they may take. But unfortunately the benzos are extremely addictive and sometimes they're used in certain populations to enhance sleep and, and reduce insomnia. But as we mentioned earlier, there are other options that seem to be a lot more effective now and have less risk of adverse outcomes. Opioid pre treatment robustly augments associative fear learning in the amygdala. Although these changes were not observed when opioids were given after the trauma. That's another really important thing. So when people had opioids in their system before the trauma, it enhanced their fear processing. That's not what we want. But when somebody was given opioids after the traumatic event, it didn't seem to enhance their fear processing and fear memory consolidation. So you know, that's just an interesting little note. But if you work with people who use because some people legit have to be on opioids for chronic pain. So people who use or people who abuse opioids, they may have a more intense fear response or traumatic response to a trauma if they were under the influence of opioids at the time. Something just to kind of put in the, in the back of your, in the back of your mind for clients that you're working with. And this is true for clients who are on suboxone, buprenorphine and methadone as well. Are there any questions about the physiological effects of ptsd?