This slideshow explores the way that stress leads to biological pathology. It attempts to connect the adverse childhood events study with Bruce McEwen's work on cortisol and stress. It explored the impact of PTSD, early childhood trauma and stress on health and longevity.

1. Beneath The Skin
Interrupting the pathways to pathology
Presented by: Michael Changaris, Psy.D.

2. 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.

3. Environmental Changes
Biological Differences
Rat Study – Generational Impacts of Adversity

4. 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

5. 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.

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

9. ACEs Smoking and COPD

10. 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

12. ACEs and IV Drug Use

13. Behavior is the Largest Predictor of Health

14. 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

15. Pathways – Adversity to Pathology
Behavior, Social Functioning and Biochemical Changes

16. 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

17. Childhood
Adversity
Effects the
Ability to
Make
Effective
Health
Decisions

18. Changes in Biological Systems

19. 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

21. Social Isolation

22. Good Social Connection

23. Environmental Changes
Biological Differences
Rat Study – Agouti Gene and Epigenetics

24. Beneath the Skin
Biology and Adversity

25. Alostatic Load…

26. Bruce McEwen, PhD
Stress Researcher

27. Pathological Adaptation

28. Systemic Dysregulation and
Disease Processes

29. Allostatic Load Index

30. 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.

31. 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/Telom
erase
5. Apoptic Factors
(e.g. Capsase 8 & 9,
Bcl2-alpha, Bax etc.)
6. Inflammation (d-
dimer, TNF-a, N-Nos,
IL1, IL6 etc.)

32. Dysregulation and Disease

34. Team Based Care

35. 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.

36. 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.

37. Adverse Childhood
Events
High
Stress
Depression
PTSD
GAD
Poor
Social
Support
Poor
Sleep
Increased
Inflammatory
Cytokines
Hip to
Waist
Ratio High
Low
SES
Poor
Coping
Skills
Elevated
Cortisol
Psychotherapy
Increased
Control at
Work
Lower Life
Stress
Reduced Pain
Healthy Diet
Physical Exercise
Statins, NSAIDs
Increased
Emotion
Regulation
Increased Sleep:
CBT, Trazadone,
CPAP etc.
Increased
Social
SupportMassage
Touch Therapy
Chocolate
Yoga Thai Chi
Increased Stress
Management and
Coping Skills
SSRI/SNRI/S
DRI

38. 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.

39. Case Discussion
 32 yr-old Caucasian Woman
 Homeless 1 yr
 Substance abuse hx, Bipolar II dx
 Insomnia
 Current depression impacting tx adherence
and decision making.
 Physical abuse by spouse and parents.
 Hyperlypidemia
 HTN
 Migraines poorly controlled
 Chronic pain LB and Legs
 Poor Medication adherence due to life stress,
financial stress & relational chaos.

40. THANK YOU!