Beneath The SkinInterrupting the pathways to pathology

Presented by: Michael Changaris, Psy.D.

Goals for today

Understand current research on childhood adversity and resilience in health.

Know the common pathways that lead from childhood adversity to pathology.

Recognize some biological markers that lead to childhood adversity transitioning disease and early death.

Begin to develop clinical tools to address impacts of childhood adversity in our patients.

Environmental Changes Biological Differences

Rat Study – Generational Impacts of Adversity

Aces Study

“When a house is burning down you do not see the flames you see the smoke. If you do not know the relationship between smoke and fire one might think that smoke was the problem and bring a fan and blow the smoke away.”

- Dr. Felitti

https://www.youtube.com/watch?v=U3iKxjk-I-8

Public Health Crisis Scope of the Childhood Adversity

More then 5.5 million children likely effected by child abuse each year (child abuse reports).

More then 16.6 million Children below the poverty line (2010).

1.5 milion Children have parents in jail.

Prenatal impacts of domestic assault, maternal stress, socioeconomic stress are endemic.

The Brain of a Severely Neglected Child Can Be 38% smaller with an IQ = 50 half of typical IQ =100

ACEs Smoking and COPD

Aces and Autoimmunity

Sixty-four percent reported at least one ACE.

34.4 men and 31.4 women out of 10,000 (first hospitalization from any autoimmune disease).

First hospitalizations for any autoimmune disease increased with increasing number of ACEs.

People with 2+ ACEs:◦ Th1 had 70% increased risk of hospitalization compared to those with

no ACEs◦ Th 2 had 80% increased risk for hospitalizations ◦ 100% increased risk for rheumatic diseases.

* All p values reported at .05

ACEs and IV Drug Use

Behavior is the Largest Predictor of Health

Developing Resiliency

Positive Family Relationships

School attachment Neighbor support Peer support/Social support Religiosity Academic Achievement Emotional support outside the family Positive Self-regard Spirituality Inner-directed locus of control Family closeness Cognitive Coping Stratigies/Emotion Regulation

Pathways – Adversity to PathologyBehavior, Social Functioning and Biochemical Changes

The Pathways to Pathology 3 Key Factors

1. Difficulty w/ Behavioral Regulation Leading to Adverse Health Behaviors.

2. Poor Social Support

3. Changes in Biological Systems

Childhood Adversity Effects the Ability to Make Effective Health Decisions

Changes in Biological Systems

Social Support – Health Outcomes

Loneliness is highly related to all cause mortality and is significant risk factor for health outcomes.

Lack of social support effects:◦ Poor Self-Concept

◦ Emotional responses and ability to regulate emotions

◦ Problem solving – attempting to solve life's problems with out the advice, support or mentorship of others (e.g. you have to make all the mistakes yourself)

◦ Effects multiple biological systems from cortisol to insulin

Social Isolation

Good Social Connection

Environmental Changes Biological Differences

Rat Study – Agouti Gene and Epigenetics

Beneath the Skin Biology and Adversity

Alostatic Load…

Bruce McEwen, PhD Stress Researcher

Pathological Adaptation

Systemic Dysregulation and Disease Processes

Allostatic Load Index

Allostasis and Health

Higher allostatic load scores associated with:

◦Poorer cognitive fxn.◦Physical functioning. ◦Predicted larger decrements in cognitive and physical

functioning. ◦ Increased risk for the incidence of cardiovascular disease

Allostatic Load predicted these outcomes independent of sociodemographic and health status risk factors.

Seeman, Teresa E., et al. "Price of adaptation: allostatic load and its health consequences: MacArthur studies of successful aging." Archives of internal medicine 157.19 (1997): 2259-2268.

Bottom Up

Top Down1. Regulated Sleep

Cycles

2. Healthy Diet

3. Cortisol

4. Circulation

5. Pain Management

6. Exercise

7. Increased Healthy

Psychological

Coping

8. Social Support

9. Meaning/Purpose

1. Glucose

Metabolism

2. Blood Pressure

3. Triglycerides

Cholesterol

4. Telomeres/

Telomerase

5. Apoptic Factors (e.g. Capsase 8 & 9,

Bcl2-alpha, Bax etc.)

6. Inflammation (d-

dimer, TNF-a, N-Nos,

IL1, IL6 etc.)

Dysregulation and Disease

Team Based Care

Importance of Treatment Teams

Increased continuety of care.

Defined roles can lead to effective collaboration and improved patient outcomes.

Increased job satisfaction and reduced burn out.

Address health complexity, patient defined goals and support the patient to be an active participant in health.

Building Health Teams

Five key factors: Trust, Communication, Commitment, Accountability and Results.

Create role clarity, pathways for communication, and point person for health goals.

Culture of a profession can develop a culture of interprofessionalism.

Clean house. Deal with challenges to team care openly and quickly.

Adverse Childhood Events

High Stress

Depression PTSD GAD

Poor Social

Support

Poor Sleep

IncreasedInflammator

yCytokines

Addictive

Behaviors

Hip to Waist

Ratio High

Low SES

Poor Coping Skills

Elevated

Cortisol

Psychotherapy

Increased Control at

Work

Lower Life Stress

Reduced PainHealthy Diet

Physical ExerciseStatins, NSAIDs

Increased Emotion

Regulation

Addiction Tx e.g. SBRT

Increased Sleep: CBT, Trazadone,

CPAP etc.

Increased Social

SupportMassageTouch Therapy

Chocolate Yoga Thai Chi

Increased Stress Management and

Coping Skills

Risk FactorsIntervention

s

SSRI/SNRI/SDRI

Patient Centered Biopsychosocial Care Planning

Patient Driven Health Goals? – Developed in collaboration w/ PCP and health team.

Creating Continuity of Care? – Identifying gaps in treatment, adherence problems, follow through, stressors (ABC – Antecedent, Behavior, Consequence).

Building Care Team? – Who is on the team? Defined by the best way to support PT to reach health goals. Defining roles.

Incremental Implementation? – Do enough but not too much. Support PT to develop new tx goals as previous goals are accomplished.

Case Discussion

32 yr-old Caucasian WomanHomeless 1 yrSubstance abuse hx, Bipolar II dxInsomniaCurrent depression impacting tx adherence

and decision making. Physical abuse by spouse and parents.HyperlypidemiaHTNMigraines poorly controlled Chronic pain LB and LegsPoor Medication adherence due to life stress,

financial stress & relational chaos.

THANK YOU!