Posttraumatic Stress Disorder in Patients with HIV: Intergrading medical and psychological treatment.

Extensive evidence has indicated that the majority of people living with the Human Immunodeficiency Virus (HIV), almost certainly suffer from posttraumatic stress disorder (PTSD). The complexities of PTSD in people living with HIV or AIDS are extensive and may negatively impact their overall HIV treatment, bearing in mind that a person's mental health greatly influences one’s health-related behaviours and quality of life (www.nlm.medlineplus/ency/article.htm). It is therefore important to raise awareness to the extent in which psychological treatment must be integrated with the medical treatment of people living with HIV and AIDS.

The Diagnostic and Statistical Manual of Mental Disorders (4th edition) stipulates that the defining characteristic of a traumatic stressor is the presence of a threat to a person's life or a threat in which the person's response involves intense fear, helplessness, or horror. Similarly HIV–positive individuals experience symptoms of associated trauma which may eventually lead to PTSD. They are exposed to a traumatic life event by receiving the HIV positive diagnosis and then having to live with the medical condition which may drastically contribute to their continued trauma (www.nlm.medlineplus/ency/article.htm).

Individuals confronted with an HIV – positive diagnosis most frequently will react with initial shock, numbness, disbelief and consequently anxiety and depression. HIV positive individuals face various psychological challenges during the course of the disease. This includes numerous traumatic factors such as receiving the diagnosis of AIDS, beginning new treatment programmes, discontinuing treatment, the appearance of new symptoms, relapse and terminal illness (www.nlm.medlineplus/ency/article.htm).

In addition to flashbacks or disturbing thoughts after receipt of their diagnosis, a PTSD diagnosis can negatively impact the course and advancement of HIV/AIDS in a number of ways. HIV infected people with PTSD, for example, tend to report more health problems. Studies have also found that a diagnosis of PTSD correlates with high indications of depression and anxiety; this may be a dominating factor which may interfere with the individual’s adherence to antiretroviral (ARV) treatment (www.ptsd.about.com/od/related.conditions/a/depressionPTDS.htm.).

The majority of public health care practitioners are unaware of the importance of not only providing medical treatment for HIV/AIDS, but also the importance of providing treatment for PTSD. Examining PTSD symptoms in medical settings where HIV–positive individuals are treated is imperative in order to identify those individuals most at risk for PTSD. It has been indicated that counselling is offered at local clinics from either HIV counsellors upon the person's diagnosis with HIV, or from ARV adherence counsellors for people with a HIV positive status. However, counsellors and medical staff at these clinics may not be adequately qualified or supervised to provide appropriate assessment and therapeutic intervention for traumatised patients (Saraceno et al., 2007). A good recommendation proposed by the Human Science Research Council (HSRC), is to have medical and counselling staff at various HIV clinics in the public sector. These professionals need to be appropriately trained in order to evaluate trauma symptoms among HIV positive individuals and to subsequently refer those at risk for PTSD for suitable therapeutic treatment. (HSRC, 2006)

Research studies in South Africa have indicated that the majority of HIV–positive individuals in need of treatment for common mental disorders such as depression and anxiety do not receive it (Saxena et al., 2007.) The severe shortage of mental health professionals in many low and middle income countries, including South Africa, is a major reason for this large treatment deficiency. It is therefore crucial to integrate mental health care and psychosocial support of HIV positive people in South Africa into the general healthcare system. The various barriers to resourceful mental health interventions and services in South Africa require further investigation. It is essential to ensure that the mental health and well-being of these individuals are both appropriately evaluated and adequately implemented.

References

Human Science Research Council (2005). South African National HIV Prevalence, HIV Incidence, behaviour and Communication Survey, 2005. Cape Town: HSRC Press.

Jacob et al., Sharah, P., Mirza, I., Garrido-Cumbera, M., Seedat, S., Mari, J., Sreenivas, V., Saxena, S., (2007). Mental Health Systems in Countries: Where are we now? Lancet, 370, 1061 – 1076.

Joshua J., Matacotta, M.A , Posttraumatic Stress Disorder in Patients with HIV: A Review of the Current Literature. [ Mar 2, 2010]. www.nlm.medlineplus/ency/article.htm.

Matthew HYPERLINK "http://ptsd.about.com/bio/Matthew-Tull-PhD-26501.htm"TullHYPERLINK "http://ptsd.about.com/bio/Matthew-Tull-PhD-26501.htm". PTSD and HIV/AIDS. [January 29, 2012]. www.ptsd.about.com/od/related.conditions/a/depressionPTDS.htm.

Saraceno, B., Ommeren, M., Batniji, I., Cohen, A., Gureje, O., Mahoneye, J., Sridhar, D., Underhill, C., (2007) Barriers To Improvement of Mental Health Services in Low - Income and Middle - Income Countries, Lancet, 370, 1164 – 1174.

Saxena, A., Thornicroft, G., Knapp, M., & Whiteford, H ( 2007). Resources for Mental Health: Scaricity, Inequity and Inefficiency. Lancet, 370, 878 -889.

Five Elements of Successful Trauma Intervention

There have been many discussions and arguments when it comes to how best to treat a trauma victim, so as to prevent the future onset of PTSD.  There are too many views and ideas to even mention here, but a number of recognized international experts published their consensus on five essential elements of immediate and mid-term mass trauma intervention Hobfoll et. al (2007).  These five elements incorporate Hobfoll’s COR (Conservation of Resources) theory and have a reasonable empirical basis. They are essentially formulated to deal with trauma on a community level, resulting in the ultimate goal of self-empowerment for future maintenance.  . One should bear in mind, however, that as with the traumatic incident itself, the individual is also unique and different people and situations require different interventions.  These elements are at most a framework on which to base trauma interventions.

1.    Promote a sense of safety

When people are exposed to a traumatic event, their normally protected environment is threatened and their perceptions of reality change.  It has been shown that once a sense of safety is restored the threat of developing PTSD decreases. A person who has experienced the trauma needs to separate their perceptions of safety from their actual safety.  After a traumatic event, it is common to develop a twisted view that the world, in general, is no longer a safe place and never will be.  If they are able to separate this belief from reality, and re-establish a sense of safety, research has shown that their symptoms after the incident with decrease. In order to assist this process, one needs to assist by giving corrective information, as well as appraise the past and future threats in a realistic manner.

Restoring the faith in a sense of safety is usually a lengthy process and must include a social systems perspective, as the community plays a large role and can affect the process positively and negatively. Safety includes protection from rumours, bad news, and negative media.

2.    Promotion of Calming

A traumatic event will almost always result in marked increases in emotionality and arousal.  This is completely normal, to a certain degree, but should decrease with time.  It becomes a problem when it begins to interfere with sleep, hydration, eating, and making life decisions.  One study showed that a person’s heart rate, following a trauma, could actually indicate whether they were at risk of developing PTSD or not.  This study  has not been confirmed, but it is interesting in note how emotionality affects recovery.  It is therefore essential that a sense of calm is promoted as soon as possible to prevent this prolonged state of hyper arousal.

Ways in which to assist with this process include therapeutic grounding where the client is assured that they are no longer in the threatening situation.  Other relaxation techniques, such as breathing retraining, deep-muscle relaxation, yoga, mindfulness, music paired with certain images and some calming medications have been shown to help too.  SIT (Stress Inoculation Training) and Exposure Therapy have also been shown to assist.  It is important that the person’s emotionality is not pathologized, but should also not be under-pathologized.  By twisting the truth though, in order to calm someone, is doing more damage than good by undermining the trauma they have experienced.

3.    Promotion of Sense of Self-Efficacy and Collective Efficacy

In life, believing that one’s actions can lead to a positive outcome, but even more so following a traumatic event, it is vitally important. This is self-efficacy.  Collective efficacy refers to the belief that one belongs to a group whose actions can lead to positive outcomes.  After a trauma, people lose confidence in their abilities to believe that they can handle issues that they may face. It is absolutely fundamental to reverse these feelings of a lack of competency in themselves, their families and their community, in order to regulate emotions.

In order to do this, the person must be made to believe they possess the necessary skills.  CBT (Cognitive Behaviour Therapy) has been shown to make the person feel that they are the expert of a certain situation, and give them necessary coping skills so that they no longer require the assistance of a trained professional.  It is also important to rebuild the sense of the community and its efficacy.  Community mass rallies, religious activities and collective rituals can do this. When a community is successful and cohesive, this will flow down to the family as well as the individual level.  To further assist with this, empowerment must be the focus.  Having to rely on trained experts and disaster aid to address community needs, can easily lead to further set the community back.

4.    Promotion of Connectedness

There has been a huge amount of research done on the importance of social support and connection in trauma recovery.  It provides a space to relate and compare experiences as well as formal and informal support groups. A lack of social support and connections is recognized as one of the important risk factors for PTSD, but how exactly to translate this to an intervention has not yet been researched. However, approaches such as creating awareness about the social connections that are available and how to connect to them could assist. It is also important to eliminate negative social support where the victim is criticized or undermined. It is vitally important to identify those who seriously lack any positive social support/connections, and focus on them and building their social skills as they are the most at risk.

5.    Instilling hope

Those who remain positive following a trauma have been shown to have more favourable outcome and recovery than those who are unable to. Therefore, instilling hope and promoting positivity are paramount in trauma interventions. Victims will often respond to trauma with a “shattered world view” and this negativity and lack of hope can deplete their coping skills leaving them more vulnerable to PTSD. Hope, in relation to psychology, has been defined as “positive, action–oriented expectation that a positive future goal or outcome is possible” (Haase, Britt, Coward & Leidy, 1992). Restoring this lost hope can include a strong belief in a God, a responsive government, or a positive superstitious belief, as well as positive mass media messaging. On an individual level, CBT (Cognitive Behaviour Therapy) has shown to help by decreasing the individual’s exaggeration of personal responsibility. CPT (Cognitive Processing Therapy) has been shown to help decatastrophize and the simple act of therapy shows a belief that with help things can get better. On a mass level, schools, universities, the media and natural community leaders can help enforce and rebuild hope by helping people focus on the positive and by rebuilding strengths by retelling stories

In conclusion, these 5 elements are core and should be included in all interventions and can be applied to all interventions, both individual and mass.  More broader-based interventions are needed to include the communities and to make treatment more accessible to those who actually need it.  This will also help provide empowerment for these communities which will assist with continued promotion of trauma prevention and assistance. These 5 principles are not, however, meant to suggest that they are all that is needed or that there is one approach that will suit ever situation, but it is certainly a step in the right direction.

The TraumaClinic Model for Trauma Support: How family, friends and employers can support victims after a traumatic event

Traumatic events are usually unexpected, shocking and overwhelming, and it is common for victims to have strong emotional reactions. Family and friends may also feel overwhelmed and at a loss of how to react appropriately, as do employers after a work related trauma incident.

 TraumaClinic’s model for Trauma Support is a model that assists professionals and empowers the lay person to offer support that can sufficiently help a victim along the path to recovery. The model systematically addresses the stages of recovery after a traumatic event, it explains what normal responses to an abnormal event are and it emphasises the factors that can optimise a victim’s recovery.

It is important to note that there is not one ‘standard’ pattern of responses to the extreme stress of traumatic events. Some people feel the impact immediately; some have a delayed response while some recover rather quickly. The type and severity of the traumatic event also influences a victim’s risk to develop Posttraumatic Stress Disorder (PTSD). Rape victims, for example, have the highest incidence of PTSD while victims of criminal violence, motor vehicle accidents and natural disasters have a low incidence of PTSD. 

What makes a difference though to a victim's risk of developing full blown PTSD or other depressive and anxiety disorders are, very importantly, positive social support from significant others. Knowing what emotional and behavioural responses to expect, and knowing what they can do to help recovery, is a first step for family, friends and employers towards supporting a trauma victim. 

The TraumaClinic model describes trauma support in terms of three stages (Van Wyk, 2004). Stage one is known as the Impact phase. The impact phase normally occurs within minutes, hours and sometimes days after the event. It is characterised by emotions of shock and denial and it is quite normal for the victim to act stunned or as if in a daze. The person may not acknowledge that something very stressful has happened and can come across as numb, confused, disorganised and disconnected from reality. One can provide support by ensuring the victim’s security and encouraging their need to restore safety. After an armed robbery a victim may for example feel safer by installing an electric fence or by buying a giant canine breed. This must be encouraged and not dismissed. Acknowledge the fact that the person has had a bad experience, and that what they feel is valid. Practical assistance is often what most victims need and a simple act such as transport or warm clothes can alleviate immediate feelings of distress.

Stage two is referred to as the Recoil phase and occurs within the following two weeks after the traumatic event. It is characterised by emotional turmoil and/or withdrawal. During this phase feelings become intense and at times unpredictable. The person may become preoccupied with the event and experience mood swings, irritability, anger and guilt.  It is common to find victims of trauma to be especially anxious or nervous and even depressed which can lead to disrupted sleep and eating patterns. During this phase it is also common that the victim will want to avoid anything related to the event and must be encouraged to get ‘back on the horse’ immediately after the event. It is advisable that employees go back to work and employers must not enforce leave, although they must give their employees the opportunity to settle gradually in their routine and responsibilities.

Greater conflict, such as more frequent arguments with family members and co-workers, can occur and should not be taken personally. On the other hand, the person may become withdrawn and isolated and avoid usual activities. Once again the validation of the victim’s feelings is important and can be established through listening and empathising with their situation. Statements like “lucky it wasn’t worse “or “don’t think about it” and “put it behind you” is not helpful to the person’s recovery. Professional counselling can be implemented to assess risk factors that may hamper recovery and to prevent the onset of complications. Counselling, for example in the form of group discussions, helps people realise that other individuals in the same circumstances often have similar reactions and emotions. Encourage the victim to engage in healthy behaviours to enhance their ability to cope with the excessive stress while substances such as alcohol or drugs must be avoided.

Trauma reactions typically diminish within two to four weeks after the event and the person will experience a gradual relieve from symptoms.  During stage three, the Reorganisation phase, feelings become more manageable, life returns back to normal and the person starts to regain a sense of control. Some symptoms may remain although it does not interfere with the person’s daily activities. During this phase victims often report of finding meaning in the experience. After approximately three weeks, if it is evident that the person is not settling down and not resuming their normal life, professional help should be sought. Treatment for Acute Stress Disorder is available, and it is wise not to wait longer. With children, continual and aggressive emotional outbursts, serious problems at school, preoccupation with the traumatic event and continued and extreme withdrawal, point to the need for professional assistance.

The TraumaClinic model for Trauma Support successfully stepped away from the conventional CISD model, that has debriefing and re-experiencing of the traumatic event as the core of its intervention, to a model that emphasises the early identification and treatment of factors that can hamper recovery. What is significant to the lay person is that the model also focuses attention on resources that can promote recovery and how social support, especially that of significant others, are essential for a victim’s recovery.

Those most at risk... of not being helped

Conservation of resources (COR) theory holds that stress is the result of an individual’s resources being threatened or lost, where resources are that which an individual values – social status, positive social support, knowledge, some personality traits, employment, access to various facilities and so on (Hobfoll 1989). When a person is confronted with a traumatic situation (perhaps retrenchment, illness, or loss of a loved one) they utilise their various resources to cope with the arising stress. A person with many resources is far better equipped to cope with stress than a person with limited resources, leaving those people in underprivileged communities particularly vulnerable to stress.

While people value a range of resources, here we’ll just be looking at one particular resource area – financial stability and employment. Let’s start with an example.

Two men are retrenched. While both have their social status threatened, the one owns his house, has numerous investments and his education and experience make him a desirable candidate for further job opportunities. Even without his job, he is financially stable for a few months at least. The second man rents the home that houses him and eight others, of which he is the sole breadwinner. The loss of his income has a significantly negative effect on the family’s ability to pay their rent, put food on the table, see to the health of their children and pay school fees. The first man, with access to a more comprehensive set of resources is more able to cope with his stressful situation than the second man whose resources are already strained.

What stands out here is that 1. underprivileged communities are at risk, and 2. that building resources (practical assistance) may be an effective way to empower individuals and families in these high risk communities so that they are able to better cope with stress and trauma. Strengthening this proposition is the findings of a number of recent studies which have called into question the effectiveness of debriefing as an effective means of long-term coping with, or, recovering from trauma, and suggested that practical help may be far more beneficial and effective – such as aiding the person with transport and ensuring safety.

Having a job and a steady income is a resource that many members of underprivileged communities lack, and one which, if equipped with, could have a positive ripple effect from the personal, to the family and even the community. But in helping underprivileged communities build this crucial resource, is there a role for the psychological community? In other words, how practical can trauma counselling be?

While members of the psychological community involved in trauma assistance cannot provide jobs or employment opportunities for underprivileged communities at large (this being the job of development practitioners, certain NGOs and government to name a few), perhaps there are a number of other areas where the psychological community can provide valuable assistance.

1.    Therapists need to have a comprehensive referral list at their fingertips in order to help their clients receive the most appropriate care – contact numbers for social workers, specialist psychologists and even possibly a legal advisor.  With regards to building the resource of employment, therapists could involve themselves in linking clients to NGOs and government initiatives aimed at providing employment – such as the public works programme being developed in South Africa.

2.    There may also be a role for members of the psychological community in influencing and developing policy with regards to promoting employment opportunities and programmes in underprivileged communities. Psychologists may well be able to provide important psychological insights and perspectives.

3.    Additionally, psychologists and counsellors can contribute valuably by assisting community members in building and enhancing their self-esteem and life skills in general – valuable tools when looking to secure a job.

As members of the helping professions there is need to further develop our thinking on how appropriate, meaningful and long-term assistance can be provided to those most at risk of stress and trauma. If arrows point to the importance of practical assistance, then trauma counselling as we know it needs to be reformulated – a process requiring us to think outside the usual parameters of psychological intervention and possibly make some strong changes in the way trauma counselling is carried out.