Post-traumatic stress disorder (PTSD) is often thought about in the setting of war and the military, but there are numerous other high-risk groups and types of traumatic experiences that may precipitate PTSD. In fact, studies suggest 20-40% of HIV-positive people meet criteria for PTSD, which is two to four times higher than in the general population.1-3
Larry is a 43-year-old, successful accountant who has been living with HIV for the past 10 years. He has had a stably suppressed viral load since starting antiretroviral treatment seven years ago. He comes to the clinic for a routine care visit. Before his exam, I review his chart and am surprised to see his viral load is now 1,750 copies/mL. Larry is unshaven and seems distant when I greet him. He appears unsettled and fidgety, which is highly uncharacteristic.
PTSD is a severe anxiety disorder that can occur in people who have experienced major psychological distress, or trauma, as a result of a serious adverse life event. These events typically involve concern for serious injury or death, or a threat to physical safety. They invoke a response of horror, intense fear, and a sense of helplessness.
Common Symptoms of Post-Traumatic Stress Disorder (PTSD)
Re-experiencing the traumatic event:
Avoidance and numbing:
Increased arousal and emotional volatility:
Traumatic Life Events Commonly Experienced Among People Living With HIV
These psychological, emotional, and physical symptoms are normal responses after experiencing a traumatic event. When symptoms last for longer than one month and interfere with social and/or occupational functioning, however, a diagnosis of PTSD is considered. Not everyone who experiences traumatic events will go on to develop PTSD, which occurs in roughly one out of five people following trauma.
Symptoms are further classified as "acute" if present for less than three months, and "chronic" if they last longer than three months. PTSD is described as "with delayed onset" if symptoms begin six months or longer after the traumatic event occurs. This is less common, as most people diagnosed with PTSD experience symptom onset shortly after the traumatic event.
The lifetime occurrence of traumatic events is incredibly common among HIV-positive people -- greater than 90% of individuals have experienced at least one in a range of events (see sidebar). The diagnosis of HIV itself may serve as a traumatic event. Other traumatic events include physical and sexual abuse, experienced by roughly 50% of people living with HIV, or other childhood and adult events involving the individual and/or family and loved ones, especially parents, children, and spouses or partners.
In one larger study, the average number of different traumatic events experienced by people living with HIV was three, with some having experienced as many as 12 distinct types of events.4 Individuals who have experienced traumatic events are at increased risk of future traumatic events -- commonly referred to as "re-victimization."
Despite the high frequency of childhood physical and sexual abuse and other traumatic life events in their HIV-positive patients, most clinicians do not routinely screen for PTSD.
When I initially probe as to what's going on, Larry gives a dismissive response and assures me everything is okay. Upon further questioning, he breaks down and explains that a new boss at work reminds him of an uncle who abused him as a child. He's been feeling angry, agitated, and has had difficulty concentrating at work. He's not sleeping well and is plagued by intrusive thoughts about the abuse he experienced as a child. He feels distant from his partner and out of touch with his emotions. Larry needs help.
Traumatic life events have important implications for health behaviors and outcomes in people living with HIV. A number of studies have shown the damaging impact of PTSD on medication adherence, sexual risk behaviors, and HIV disease progression.1-4
A robust collection of literature has linked traumatic life events, even in the absence of PTSD, with a range of unhealthy behaviors and outcomes. It shows that people who experience a higher number of distinct traumatic life events are more likely to engage in unprotected sex, be non-adherent to their antiretroviral medications, go to an emergency room or become hospitalized, and report lower overall health and well being, with greater risk for HIV disease progression.
Stressful life events are also incredibly common among HIV-positive people, especially those who have experienced past traumatic events. Day-to-day stress -- like that related to finances, relationships, employment, safety, life transitions, and legal issues -- has a major impact on health and behaviors.5 That includes things such as foreclosure, not having money to pay bills, separation from a spouse or partner, being burglarized, or being arrested and put in jail or prison.
As seen with lifetime trauma and PTSD, people living with HIV that experience stressful life events are more likely to engage in unprotected sex, not take antiretroviral medications as prescribed, and experience viral load failure. This is magnified in the setting of past traumatic events, leading many to advocate for routine trauma and PTSD screening as a normal component of HIV clinical care -- particularly because several brief tools are available to conduct such assessments.3
It is widely recognized that mental illness, especially depression and substance abuse, are common conditions in people living with HIV. Similarly, the relationships between depression, substance abuse, and adverse health-related behaviors and outcomes are equally well known.
Perhaps less commonly discussed is the overlap between trauma, PTSD, mental illness, and substance abuse, which is extremely common and of concern on numerous levels. Namely, each of these conditions is linked to unhealthy behaviors and unfavorable outcomes on their own. When combined, the impact is even further exacerbated. Moreover, as observed in those with PTSD, difficulty in establishing trust and utilizing social support may interfere with care-seeking and management of mental illness and substance abuse.1
To date, studies have shown that these relationships are incredibly complex and that it is not easy to untangle the roles of trauma, PTSD, mental illness, and substance abuse in terms of how they interact and lead to negative health effects.1-4 Research has tried to better understand the relationships between these common co-occurring conditions. Do childhood traumatic events predispose someone to depression and substance abuse? Do past traumatic events and PTSD negatively impact health behaviors and outcomes by way of increased risk for new stressful life events and re-victimization? Or is reoccurrence of trauma and PTSD perhaps due to a higher frequency of mental illness and substance abuse? While there may not be definitive answers, it is clear that these conditions commonly co-occur and when they do, their adverse impact on health and well being are increased.
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