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!