The importance for Primary Care

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1 Trauma-informed care and the Adverse Childhood Experiences study: The importance for Primary Care Eva Purkey MD, CCFP

2 TW: 35 yrs old - moved from Calgary fall 2013 to escape abusive relationship - hx of work in sales (car companies, cable companies) - taking classes to become a minister - 7 year old son - history of drug and ETOH use (resolved) - history of physical abuse from father and brother - history of emotional abuse from both parents - hereditary essential tremor - recurrent UTIs - fibromyalgia - sciatica - ADD - anxiety - query borderline personality disorder - insomnia - nervous around people - nightmares

3 Outline ACE study Complex PTSD Trauma Long-term health effects of Trauma Introduction to trauma-informed care

4 The ACE study Cohort of 17,000 middle-class insured Americans (2 waves: 1rst 9,508 participants) 80% white 74% had attended some college 50% female Average age of 57

5 The ACE score: Scored out of 10, looking at 3 categories: Neglect Abuse Household Dysfunction

6 Findings: prevalence of Adverse Childhood Experiences 33% 28% 27% 22% 17% Score of 0 Physical abuse Sexual abuse Family member abusing drugs or EtOH ACE of 4 or more

7 Complex PTSD: a short history Freud publishes the Aetiology of Hysteria, describing hysteria and dissociation as responses to unbearable emotional trauma, often related to premature sexual experiences Diana Russell: 25% of women report rape; 1/3 of women report sexual abuse as children Term complex PTSD coined by Judith Herman in the book Trauma and Recovery IOM report: inadequacy of health practitioner training

8 Complex PTSD: some diagnostic criteria 1. A history of subjection to totalitarian control over a prolonged period 2. Alterations in affect regulation 3. Alterations in consciousness 4. Alterations in self perception 5. Alterations in perception of the perpetrator 6. Alterations in relations with other 7. Alterations in systems of meaning

9 Question to you: How often could the idea of complex PTSD replace what is now referred to as borderline personality disorder given some of the previous characteristics?

10 A different paradigm: Perhaps such behaviors should not be viewed as pathology, but rather as adaptive behaviors to extreme or unmanageable emotional and developmental trauma

11 LM: 35yrs old - Genetic syndrome associated with lisp and hearing loss - Insomnia - jumps if touch unexpectedly - chronic anxiety attacks - sexually abused by her father and father s friend from age 9 - witnessed sexual and physical abuse of her mother by her father - father was alcoholic and king-pin in drug trafficking scene - drug abuse starting at age 9 - currently only smokes cigarettes: no drugs or EtOH - finished high school as an adult - cares for her mother who has recent cancer diagnosis - full time unionized job - history of very abusive relationships with men

12 Trauma An event may be experienced as trauma if: 1. It was unexpected 2. The person was unprepared 3. There was nothing the person could reasonably have done to stop it from happening Social support is key to the experience of trauma and to people s ability to integrate their experiences

13 Trauma-informed: the trauma toolkit; Klinic Community Health Centre

14 The impact of adverse childhood experiences

15 Alterations in Hypothalamicpituitary-adrenal axis (HPA): feedback mechanism is altered in persons exposed to violence and abuse Increase in substance P (elevated in veterans with PTSD, and also in pts with somatic syndromes) Somatic syndromes Sexual risk behavior Cancers Alterations in DNA damage and repair via immune system and HPA axis Changes in pulmonary immune system Respiratory illness Obesity Altered serotonin receptors and responsiveness Mental health Cardiovascular disease Addictions Increase in NE and exaggerated CNS response to NE Increase inflammatory markers (including IL, TNF, CRP)

16 Trauma-informed care WHY? HOW? WHAT?

17 - Smoker - Addicted to percocets (12/d) - Anxiety - Anger management BT: 54yrs old - Chronic back and neck pain - Hepatitis C - Cirrhosis - Familial polyposis with colectomy - Severe physical and emotional abuse by father in childhood - Father was alcoholic - Left home at age 12 - No-showing for colonoscopies - Refusing to attend GI for cirrhosis and hep C management - Weaned off percocets: no more chronic pain - Stopped smoking - Working full time - Triggered by GI specialists: any paternalistic or judgemental conversation is trigger for anxiety and anger, as is physical space of clinic

18 Herman s steps to recovery Seeking Safety Reconnecting Remembrance and Mourning

19 How? Safety Empowerment Trustworthiness Collaboration Choice

20 Resources & references Trauma-informed: the trauma toolkit (2013: Klinic Community Health Centre) Herman Judith. Trauma and Recovery Keeshin, Cronholm, Strawn. Physiologic Changes Associated with Violence and Abuse Exposure: An Examination of Related Medical Conditions. Trauma, Violence and Abuse, Dec 2011 Elliott, Bjelajac, Fallot, Markoff, Glover Reed. Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. Journal of Community Psychology. Vol 33 No Felitti, Anda. The Relationships of Adverse Childhood Experience to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare. From: The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Cambridge University Press 2009

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