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The impact of PTSD on treatment adherence in persons with HIV infection†
General Hospital Psychiatry 23 (2001) 294 –296
Letters to the editor The impact of PTSD on treatment adherence in persons with HIV infection† To the Editor: Early childhood physical and sexual abuse are major public health problems [1] and among the traumas most commonly associated with the development of post-traumatic stress disorder (PTSD) [2]. Estimates for the lifetime prevalence of PTSD in the general population range from 8% to 14% [3]. According to general population surveys, the prevalence of early childhood sexual trauma ranges from 4% to 13% [1]. Among the medically ill, and specifically among those who are HIV infected, the prevalence of early childhood trauma and PTSD may be higher. In one study, 65% of HIV infected persons reported being sexually abused as children [4]. Researchers have examined the association between childhood abuse and HIV risk behaviors in an effort to design preventive interventions that could reduce the risk of viral transmission [5,6]. Research has not focused on the treatment of the behavioral concomitants of PTSD. Patients with PTSD often engage in abusive relationships and selfdestructive behaviors. Nonadherence or noncompliance with risk reduction and medical treatment can be interpreted as self-defeating and self-destructive behavioral manifestations of PTSD and early childhood trauma. The following cases illustrate the association between early childhood trauma, PTSD, and different levels of adherence to medical treatment in persons with HIV infection receiving on-site psychiatric care in an ambulatory AIDS clinic.
2. Case 1 A 32-year-old HIV-seropositive woman was referred for psychiatric consultation for treatment refractory depression and intense carbohydrate craving. At the time of her referral, she had been followed by her primary physician for 6
* Corresponding author. Tel. (212) 787-4265; fax: (212) 831-1127 † Dr. Carrera was an extern at Mount Sinai Medical Center when writing this paper. She is currently completing her psychiatry residency at St. Lukes-Roosevelt Medical Center. E-mail address: [email protected] (M.A. Cohen)
years. She was on antiretroviral agents and paroxetine. Her viral load was 3344 and her CD4 count was 560. She frequently missed appointments. Her psychiatric symptoms included persistent sadness, anergia, anhedonia, hypersomnia, hyperphagia, and hopelessness about her medical condition. She also exhibited hypervigilance, easy startle, nightmares, numbing, and a sense of foreshortened future. Her history was significant for opioid, cannabis, and cocaine dependence. She was enrolled in a drug program on methadone, 90 mg daily, but was still using heroin sporadically. The patient was physically, emotionally, and sexually abused as a child. She was abused by her stepfather from the age of 7. She was subsequently sexually abused by a cousin and two uncles. She had recurrent nightmares and depression. At the age of 26 she was raped. She found solace in heroin use and supported her habit by engaging in commercial sex. She attempted suicide three times. Psychiatric examination revealed depression, but no suicidal ideation, psychosis, or cognitive deficits. The patient had a history of nonadherence with both antiretroviral and psychiatric medications. Paroxetine was discontinued and she was started on citalopram and gabapentin. She expressed the desire to continue with psychodynamic psychotherapy but frequently missed appointments. Over the course of 10 months she missed more than 50% of her appointments despite monthly to weekly outreach by telephone. Gradually, she discontinued heroin use and began to engage in care.
3. Case 2 A 35-year-old woman was referred for psychiatric consultation for worsening depression following a stressful separation from her second husband. She had been depressed for 7 years, because she was diagnosed HIV positive. Her CD4 count was 300 and viral load 400 at the time of the consultation, with a nadir CD4 count of 90, fulfilling criteria for an AIDS diagnosis. Since her HIV diagnosis, she attempted suicide four times. Her history was significant for alcohol and cocaine dependence for more than 1 year. The patient was repeatedly and severely abused physically, sexually, and emotionally by her alcoholic father from age of three to age 16 years. The patient and her younger brother were both severely traumatized by the exposure to violence as children. Their father was an alcohol dependent
0163-8343/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved.
Letters to the Editor / General Hospital Psychiatry 23 (2001) 294 –296
gambler who abused not only his children but also his wife. The patient married at 16 to escape from her abusive father but divorced after 6 months. She used alcohol and cocaine to escape from feelings of depression and intrusive thoughts. The patient met her second husband at a drug rehabilitation program. He was not abusive until she began to confront him about using and selling drugs. He then became violent towards her. She obtained an order of protection, pressed charges, and had him arrested. She had nightmares, hyperarousal, intrusive thoughts, and claustrophobia. She had recurrent dreams about the funeral of a little girl and awakened fearful. Psychiatric examination revealed depression, anxiety, and suicidal ideation but no plan. She had no evidence of psychosis or cognitive deficits. She responded well to citalopram, gabapentin, and psychotherapy but had poor adherence to antiretroviral medication. She kept regular appointments with her psychiatrist but missed five appointments with her primary physician during her first 5 months of psychotherapy. Gradually, she began to keep her appointments with both clinicians.
4. Case 3 A 48-year-old single, HIV-positive man was referred for psychiatric consultation for agoraphobia and panic attacks. At that time, he was unemployed and lived in a single-roomoccupancy hotel. The patient was abandoned by his father at birth. From age 6 to 12 he was severely abused by his older brother, both physically and sexually. His mother died of cancer when he was an adolescent. He was raped at knifepoint as a young adult and was gang raped at gunpoint several years later. He had insomnia, nightmares, hyperarousal, dissociation, hypervigilance, easy startle, and flashbacks of his earlier traumas. He had a sense of foreshortened future. Prior to the referral, the patient was treated with paroxetine and clonazepam without adequate symptom relief. Psychiatric examination revealed depression but no suicidal ideation, psychosis, or cognitive deficits. He was treated with weekly psychodynamic psychotherapy for 1 year and was able to deal directly with his childhood trauma. He missed appointments only in response to changes or cancellations made by his clinicians and acknowledged that he had issues of abandonment and feared rejection. His depression and agoraphobia improved and he was able to start working on a part-time basis. He was treated with citalopram, hydroxyzine, and gabapentin for depression and PTSD, and responded well. The patient’s medical condition gradually improved with antiretroviral therapy. His viral load decreased from 72,000 to 1,500 within a 2-year period, and his CD4 count increased from 90 to 217 during this time. The patient was fully adherent to his antiretroviral medications since beginning psychodynamic psychotherapy.
295
5. Discussion All three of our patients sustained brutal, chronic, and severe physical and sexual trauma during early childhood. They also sustained adult trauma with rape and domestic violence. All three had symptoms of PTSD and met diagnostic criteria. They also engaged in risky sexual behavior. Both women used drugs or alcohol to escape from their painful memories and intrusive thoughts. The women had also made multiple attempts to commit suicide and all three of our patients had symptoms of depression. The first patient engaged in commercial sex work. The second patient reenacted her early trauma in relationships with neglectful and violent men, whereas the third individual had significant separation anxiety. Patients may have difficulty talking openly about early childhood trauma or even adulthood rape or trauma. The guilt, shame, discomfort, distress, and associated defenses of suppression, repression, and denial make these topics painful taboos. To overcome taboos, a sensitive, experienced clinician needs to ask specific questions about trauma and about the symptoms of PTSD. PTSD treatment guidelines have been developed [8] and new guidelines are emerging for the care of persons with this disorder. Because clinicians may associate PTSD with combat-related violence, they may not recognize it in people who have experienced other types of trauma. DSM IV [9] clearly defines the preconditions to include exposure to threats of death or serious injury with a response of fear, helplessness, or horror and does not limit the definition to wars or disasters. The behavioral manifestations of PTSD include a difficulty in recognition of harm, problems in developing selfprotective mechanisms, and a compulsive need to repeat the trauma. The behavioral manifestations resulting from early childhood trauma and neglect leave the child with problems developing self-care, self-love, and an abiding commitment to protect the body from harm. The early paradigms of caring and nurturing are either absent or severely distorted by the traumatic events. The repetitive patterns are established in an effort to master the trauma by repetition and, at times, turning the passive into the active by partner choice. Patients may also reenact the trauma by abusing their own children or partners. The sense of foreshortened future may also contribute to problems adhering with risk reduction as well as adherence to care. Our cases poignantly illustrate these dynamics and also provide a model for care. Although one of our patients continued to actively use heroin and avoided care, outreach was continued by telephone contact. Two of our patients are actively engaged in psychotherapy, are adherent to medical and psychiatric care, and have resumed higher levels of social and occupational function. Our cases suggest an association between early childhood trauma, PTSD, and HIV
296
Letters to the Editor / General Hospital Psychiatry 23 (2001) 294 –296
infection. Hutton and colleagues have found a high prevalence of PTSD in HIV-positive women prisoners [10] and Freedman and colleagues have described a patient with PTSD and HIV dementia [11]. Cohen has described her work with persons with early childhood trauma in an AIDS nursing home population [12]. However, there are no previous reports of an association between early childhood trauma, PTSD, and HIV infection. This work and our cases suggest the need for further investigations of early childhood trauma and PTSD as cofactors in HIV transmission and adherence to care. Mary Ann Cohen, M.D.a,* Cesar A. Alfonso, M.D.a Rosalind G. Hoffman, M.D.a Victoria Milau, M.D.a Gloria Carrera, M.D. b,† a Mount Sinai Medical Center One Gustave Levy Place, Box 1009 New York, NY 10029, USA b St. Lukes-Roosevelt Medical Center 1000 Tenth Avenue Suite 6C20 New York, NY 10019
PII: S0163-8343(01)00152-9
References [1] MacMillan HL, Fleming JE, Trocme, et al. Prevalence of child physical and sexual abuse in the community. Results from the Ontatrio Health supplement. JAMA 1997;278:131–5. [2] Kessler RC, Sonnego A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Co-morbidity Survey. Arch Gen Psychiatry 1995;52:1048 – 60. [3] Yehuda R. Biological factors associated with susceptibility to posttraumatic stress disorder. Can J Psychiatry 1999;44:34 –9. [4] Allers CT, Benjack KJ. Connection between childhood abuse and HIV infection. J Counsel Develop 1991;70:309 –13. [5] Lodico MA, DiClemente RJ. The association between childhood sexual abuse and prevalence of HIV-related risk behaviors. Clin Pediatr 1994;33;498 –502. [6] Wingood GM, De Clemente RJ. Child sexual abuse, HIV sexual risk, and general relations of African-American women. Am J Prev Med 1997;13:380 – 4. [7] Lenderking WR, Wold C, Mayer KH, et al. Childhood sexual abuse among homosexual men. Prevalence and association with unsafe sex. J Gen Internal Med 1997;12:250 –3. [8] Foa EB, Davidson JRT, Frances A. Expert Consensus Guideline Series: treatment of posttraumatic stress disorder. J Clin Psychiatry 1999;60:1–76. [9] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994. [10] Hutton HE, Treisman GJ, Hunt WR, et al. HIV risk behaviors and their relationship to posttraumatic stress disorder among women prisoners. Psychiatric Services 2001;52:508 –13. [11] Freedman JB, O’Dowd MA, Wyszynski B, Torres JR, McKegney FP. Depression, HIV dementia, delirium, posttraumatic stress disorder (or all of the above). Gen Hosp Psychiatry 1994;6:426 –34. [11] Cohen MA. Psychodynamic psychotherapy in an AIDS nursing home. J Acad Psychoanalysis 1999;27:121–33.
Letters to the editor The impact of PTSD on treatment adherence in persons with HIV infection† To the Editor: Early childhood physical and sexual abuse are major public health problems [1] and among the traumas most commonly associated with the development of post-traumatic stress disorder (PTSD) [2]. Estimates for the lifetime prevalence of PTSD in the general population range from 8% to 14% [3]. According to general population surveys, the prevalence of early childhood sexual trauma ranges from 4% to 13% [1]. Among the medically ill, and specifically among those who are HIV infected, the prevalence of early childhood trauma and PTSD may be higher. In one study, 65% of HIV infected persons reported being sexually abused as children [4]. Researchers have examined the association between childhood abuse and HIV risk behaviors in an effort to design preventive interventions that could reduce the risk of viral transmission [5,6]. Research has not focused on the treatment of the behavioral concomitants of PTSD. Patients with PTSD often engage in abusive relationships and selfdestructive behaviors. Nonadherence or noncompliance with risk reduction and medical treatment can be interpreted as self-defeating and self-destructive behavioral manifestations of PTSD and early childhood trauma. The following cases illustrate the association between early childhood trauma, PTSD, and different levels of adherence to medical treatment in persons with HIV infection receiving on-site psychiatric care in an ambulatory AIDS clinic.
2. Case 1 A 32-year-old HIV-seropositive woman was referred for psychiatric consultation for treatment refractory depression and intense carbohydrate craving. At the time of her referral, she had been followed by her primary physician for 6
* Corresponding author. Tel. (212) 787-4265; fax: (212) 831-1127 † Dr. Carrera was an extern at Mount Sinai Medical Center when writing this paper. She is currently completing her psychiatry residency at St. Lukes-Roosevelt Medical Center. E-mail address: [email protected] (M.A. Cohen)
years. She was on antiretroviral agents and paroxetine. Her viral load was 3344 and her CD4 count was 560. She frequently missed appointments. Her psychiatric symptoms included persistent sadness, anergia, anhedonia, hypersomnia, hyperphagia, and hopelessness about her medical condition. She also exhibited hypervigilance, easy startle, nightmares, numbing, and a sense of foreshortened future. Her history was significant for opioid, cannabis, and cocaine dependence. She was enrolled in a drug program on methadone, 90 mg daily, but was still using heroin sporadically. The patient was physically, emotionally, and sexually abused as a child. She was abused by her stepfather from the age of 7. She was subsequently sexually abused by a cousin and two uncles. She had recurrent nightmares and depression. At the age of 26 she was raped. She found solace in heroin use and supported her habit by engaging in commercial sex. She attempted suicide three times. Psychiatric examination revealed depression, but no suicidal ideation, psychosis, or cognitive deficits. The patient had a history of nonadherence with both antiretroviral and psychiatric medications. Paroxetine was discontinued and she was started on citalopram and gabapentin. She expressed the desire to continue with psychodynamic psychotherapy but frequently missed appointments. Over the course of 10 months she missed more than 50% of her appointments despite monthly to weekly outreach by telephone. Gradually, she discontinued heroin use and began to engage in care.
3. Case 2 A 35-year-old woman was referred for psychiatric consultation for worsening depression following a stressful separation from her second husband. She had been depressed for 7 years, because she was diagnosed HIV positive. Her CD4 count was 300 and viral load 400 at the time of the consultation, with a nadir CD4 count of 90, fulfilling criteria for an AIDS diagnosis. Since her HIV diagnosis, she attempted suicide four times. Her history was significant for alcohol and cocaine dependence for more than 1 year. The patient was repeatedly and severely abused physically, sexually, and emotionally by her alcoholic father from age of three to age 16 years. The patient and her younger brother were both severely traumatized by the exposure to violence as children. Their father was an alcohol dependent
0163-8343/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved.
Letters to the Editor / General Hospital Psychiatry 23 (2001) 294 –296
gambler who abused not only his children but also his wife. The patient married at 16 to escape from her abusive father but divorced after 6 months. She used alcohol and cocaine to escape from feelings of depression and intrusive thoughts. The patient met her second husband at a drug rehabilitation program. He was not abusive until she began to confront him about using and selling drugs. He then became violent towards her. She obtained an order of protection, pressed charges, and had him arrested. She had nightmares, hyperarousal, intrusive thoughts, and claustrophobia. She had recurrent dreams about the funeral of a little girl and awakened fearful. Psychiatric examination revealed depression, anxiety, and suicidal ideation but no plan. She had no evidence of psychosis or cognitive deficits. She responded well to citalopram, gabapentin, and psychotherapy but had poor adherence to antiretroviral medication. She kept regular appointments with her psychiatrist but missed five appointments with her primary physician during her first 5 months of psychotherapy. Gradually, she began to keep her appointments with both clinicians.
4. Case 3 A 48-year-old single, HIV-positive man was referred for psychiatric consultation for agoraphobia and panic attacks. At that time, he was unemployed and lived in a single-roomoccupancy hotel. The patient was abandoned by his father at birth. From age 6 to 12 he was severely abused by his older brother, both physically and sexually. His mother died of cancer when he was an adolescent. He was raped at knifepoint as a young adult and was gang raped at gunpoint several years later. He had insomnia, nightmares, hyperarousal, dissociation, hypervigilance, easy startle, and flashbacks of his earlier traumas. He had a sense of foreshortened future. Prior to the referral, the patient was treated with paroxetine and clonazepam without adequate symptom relief. Psychiatric examination revealed depression but no suicidal ideation, psychosis, or cognitive deficits. He was treated with weekly psychodynamic psychotherapy for 1 year and was able to deal directly with his childhood trauma. He missed appointments only in response to changes or cancellations made by his clinicians and acknowledged that he had issues of abandonment and feared rejection. His depression and agoraphobia improved and he was able to start working on a part-time basis. He was treated with citalopram, hydroxyzine, and gabapentin for depression and PTSD, and responded well. The patient’s medical condition gradually improved with antiretroviral therapy. His viral load decreased from 72,000 to 1,500 within a 2-year period, and his CD4 count increased from 90 to 217 during this time. The patient was fully adherent to his antiretroviral medications since beginning psychodynamic psychotherapy.
295
5. Discussion All three of our patients sustained brutal, chronic, and severe physical and sexual trauma during early childhood. They also sustained adult trauma with rape and domestic violence. All three had symptoms of PTSD and met diagnostic criteria. They also engaged in risky sexual behavior. Both women used drugs or alcohol to escape from their painful memories and intrusive thoughts. The women had also made multiple attempts to commit suicide and all three of our patients had symptoms of depression. The first patient engaged in commercial sex work. The second patient reenacted her early trauma in relationships with neglectful and violent men, whereas the third individual had significant separation anxiety. Patients may have difficulty talking openly about early childhood trauma or even adulthood rape or trauma. The guilt, shame, discomfort, distress, and associated defenses of suppression, repression, and denial make these topics painful taboos. To overcome taboos, a sensitive, experienced clinician needs to ask specific questions about trauma and about the symptoms of PTSD. PTSD treatment guidelines have been developed [8] and new guidelines are emerging for the care of persons with this disorder. Because clinicians may associate PTSD with combat-related violence, they may not recognize it in people who have experienced other types of trauma. DSM IV [9] clearly defines the preconditions to include exposure to threats of death or serious injury with a response of fear, helplessness, or horror and does not limit the definition to wars or disasters. The behavioral manifestations of PTSD include a difficulty in recognition of harm, problems in developing selfprotective mechanisms, and a compulsive need to repeat the trauma. The behavioral manifestations resulting from early childhood trauma and neglect leave the child with problems developing self-care, self-love, and an abiding commitment to protect the body from harm. The early paradigms of caring and nurturing are either absent or severely distorted by the traumatic events. The repetitive patterns are established in an effort to master the trauma by repetition and, at times, turning the passive into the active by partner choice. Patients may also reenact the trauma by abusing their own children or partners. The sense of foreshortened future may also contribute to problems adhering with risk reduction as well as adherence to care. Our cases poignantly illustrate these dynamics and also provide a model for care. Although one of our patients continued to actively use heroin and avoided care, outreach was continued by telephone contact. Two of our patients are actively engaged in psychotherapy, are adherent to medical and psychiatric care, and have resumed higher levels of social and occupational function. Our cases suggest an association between early childhood trauma, PTSD, and HIV
296
Letters to the Editor / General Hospital Psychiatry 23 (2001) 294 –296
infection. Hutton and colleagues have found a high prevalence of PTSD in HIV-positive women prisoners [10] and Freedman and colleagues have described a patient with PTSD and HIV dementia [11]. Cohen has described her work with persons with early childhood trauma in an AIDS nursing home population [12]. However, there are no previous reports of an association between early childhood trauma, PTSD, and HIV infection. This work and our cases suggest the need for further investigations of early childhood trauma and PTSD as cofactors in HIV transmission and adherence to care. Mary Ann Cohen, M.D.a,* Cesar A. Alfonso, M.D.a Rosalind G. Hoffman, M.D.a Victoria Milau, M.D.a Gloria Carrera, M.D. b,† a Mount Sinai Medical Center One Gustave Levy Place, Box 1009 New York, NY 10029, USA b St. Lukes-Roosevelt Medical Center 1000 Tenth Avenue Suite 6C20 New York, NY 10019
PII: S0163-8343(01)00152-9
References [1] MacMillan HL, Fleming JE, Trocme, et al. Prevalence of child physical and sexual abuse in the community. Results from the Ontatrio Health supplement. JAMA 1997;278:131–5. [2] Kessler RC, Sonnego A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Co-morbidity Survey. Arch Gen Psychiatry 1995;52:1048 – 60. [3] Yehuda R. Biological factors associated with susceptibility to posttraumatic stress disorder. Can J Psychiatry 1999;44:34 –9. [4] Allers CT, Benjack KJ. Connection between childhood abuse and HIV infection. J Counsel Develop 1991;70:309 –13. [5] Lodico MA, DiClemente RJ. The association between childhood sexual abuse and prevalence of HIV-related risk behaviors. Clin Pediatr 1994;33;498 –502. [6] Wingood GM, De Clemente RJ. Child sexual abuse, HIV sexual risk, and general relations of African-American women. Am J Prev Med 1997;13:380 – 4. [7] Lenderking WR, Wold C, Mayer KH, et al. Childhood sexual abuse among homosexual men. Prevalence and association with unsafe sex. J Gen Internal Med 1997;12:250 –3. [8] Foa EB, Davidson JRT, Frances A. Expert Consensus Guideline Series: treatment of posttraumatic stress disorder. J Clin Psychiatry 1999;60:1–76. [9] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994. [10] Hutton HE, Treisman GJ, Hunt WR, et al. HIV risk behaviors and their relationship to posttraumatic stress disorder among women prisoners. Psychiatric Services 2001;52:508 –13. [11] Freedman JB, O’Dowd MA, Wyszynski B, Torres JR, McKegney FP. Depression, HIV dementia, delirium, posttraumatic stress disorder (or all of the above). Gen Hosp Psychiatry 1994;6:426 –34. [11] Cohen MA. Psychodynamic psychotherapy in an AIDS nursing home. J Acad Psychoanalysis 1999;27:121–33.