Yale Psychiatry Grand Rounds: January 29, 2021

Transcript

• 00:00A very brief a couple of very
• 00:03brief comments to Department and
• 00:05then and then pass it over to.
• 00:08Doctor Gelernter to introduce
• 00:09our grand round speaker today.
• 00:11Who I'm thrilled. To that we are
• 00:15hosting Doctor Kerriston Conan.
• 00:18So. We had planned to have a
• 00:22departmentally town Hall next. Thursday.
• 00:25To discuss the evolving vision,
• 00:29mission and values statement
• 00:33for the Department.
• 00:35I appreciate the comments that
• 00:37we received so far and also the
• 00:40feedback that it would be helpful
• 00:42before we proposed a draft of
• 00:45the Vision mission statement.
• 00:47To have some interest groups
• 00:50to get peoples input.
• 00:52Into the primary drafting of the document.
• 00:54So we're going to cancel the.
• 00:57Town Hall for next Thursday and began
• 01:00to use that as a planning strategy
• 01:03to develop a more inclusive approach
• 01:05to developing the vision mission
• 01:08values statement for the Department.
• 01:10And just wanted to let everybody
• 01:13know that we're going to send
• 01:15that out in writing to everybody.
• 01:17With that I'm going to pass it
• 01:20over to Doctor Galanter Joel.
• 01:23No thanks,
• 01:24I'm very happy to introduce Doctor
• 01:26Karsten Conan is one of the
• 01:29most influential and productive
• 01:30investigators in the field of
• 01:33PTSD and resilience research,
• 01:35especially genetics.
• 01:36Although that's not her only focus.
• 01:39Doctor Konen is professor of
• 01:41psychiatric Epidemiology at the Harvard
• 01:43TH Chan School of Public Health.
• 01:45She also has appointments at
• 01:46the Broad Institute and the
• 01:48Department of Psychiatry at MBH.
• 01:51She did her BA at Wellesley
• 01:53College Masters at Columbia, Dr.
• 01:55It'd be you and her postdoc at
• 01:57Columbia and psychiatric Epidemiology.
• 02:00She's had faculty appointments
• 02:02at BU Columbia and Harvard
• 02:04first early in her career,
• 02:06and now again since 2013.
• 02:09She has numerous major research initiatives.
• 02:11She's copii on the NIH funded Aurora study,
• 02:15which aims to improve the understanding,
• 02:18prevention and recovery of individuals
• 02:21who've experienced a traumatic event.
• 02:24She Co leads the PTSD working group of
• 02:27the Psychiatric Genomics consortium.
• 02:30And she leads the Nuro psychiatric
• 02:32genetics of African populations
• 02:33and neuro psychiatric genetics
• 02:35and Mexican populations programs
• 02:37to build collaborations in nuro
• 02:39psychiatric genetics research
• 02:40in non European populations,
• 02:42which is a critical need in
• 02:44the field of complex traits.
• 02:46Genetics in general,
• 02:48not just in psychiatric genetics.
• 02:50And she also investigates how violence,
• 02:53trauma and PTSD affect long term
• 02:55physical health and accelerate aging.
• 02:57Lot of this work is done in
• 02:59the nurses Health study,
• 03:01which is a study of risk factors
• 03:03for major chronic diseases in women
• 03:06with about 280,000 participants.
• 03:08And she plays a public role and advocacy
• 03:11for survivors of violence and trauma.
• 03:13She's received numerous honors and awards.
• 03:16She's past president of the International
• 03:19Society for Traumatic Stress Studies,
• 03:21Fellow of the American
• 03:23Psychopathological Association,
• 03:24Scientifiche Councilmember anxiety and
• 03:27Depression Association of America.
• 03:29Besides being an outstanding
• 03:31scientist and mentor,
• 03:32she's a valued collaborator and
• 03:33among her other accomplishments.
• 03:35This year she was on a podcast with
• 03:37one of the world's great songwriters,
• 03:40and he met.
• 03:43Her talk today is trauma and
• 03:45Women's Health within and
• 03:47across generations. Karsten. Thank
• 03:50you Joanne. Thank you for having me.
• 03:52Thanks for that really kind introduction.
• 03:54Embarrassing introduction and
• 03:55I really wish I could be here.
• 03:57I'll be at Yellen person to be doing this.
• 04:00An meeting with folks when we.
• 04:02I think when we plan this which
• 04:04time is we were during covid.
• 04:06But I think we thought I might be able
• 04:09to come in person but maybe you know
• 04:12maybe some time in a few months I can
• 04:14at least come and talk to people person.
• 04:17So I'm going to talk today about.
• 04:19One of my areas of research which
• 04:21is on PTSD in Women's Health.
• 04:23I'm actually not going to talk
• 04:25about my genetics research,
• 04:26which some people might
• 04:28be more familiar with,
• 04:29but I'm happy to answer questions
• 04:31about that or about any of the
• 04:33other things that Joel mentioned.
• 04:34The work we're doing in Africa.
• 04:38So um, get started and we should
• 04:40have plenty of time for questions.
• 04:42'cause I don't think I will
• 04:44take a whole hour.
• 04:46So to start.
• 04:48I have no disclosures.
• 04:52So I don't know if trauma is
• 04:55more common now than in the past,
• 04:58but it seems like we hear about
• 05:00knew traumatic events daily and
• 05:02especially about mass casualty events,
• 05:04whether it's before covid.
• 05:05What hit the news mostly was terrorist
• 05:08attacks in school shootings or disasters.
• 05:11And then you know,
• 05:12for the last almost for last year now,
• 05:15we've been dealing with the
• 05:17various aspects of cobit and
• 05:19related stressors and traumas.
• 05:23And the central point of this talk is
• 05:25to illustrate how trauma adversely
• 05:27effects Women's Health and how these
• 05:30effects extend to women to the offspring.
• 05:33So seven points for consideration.
• 05:35One, I'm sure this isn't news
• 05:37to anyone in this audience,
• 05:39but trauma exposure even before
• 05:41you know covid, it's got a lot of
• 05:44kind of press now with comments,
• 05:46so we know this from not just
• 05:48from anecdotes or media reports
• 05:50right from Epidemiology so.
• 05:52I'm in a study in the World Mental
• 05:55Health Surveys which is led by
• 05:57Ron Kessler out of Harvard.
• 05:58We surveyed a number of different
• 06:00countries an in all countries surveyed
• 06:02over half the population reported
• 06:03exposure to at least one traumatic events.
• 06:06This is these are the countries
• 06:08that were in the.
• 06:09In this study we did at the time the
• 06:12grey or places that weren't surveyed.
• 06:15And then in the US,
• 06:16consistently this isn't old data,
• 06:18but over 50% of the US population
• 06:20export exposure to more than one trauma.
• 06:23So well.
• 06:24When I started in the field now
• 06:26quite awhile ago,
• 06:27people kind of considered trauma
• 06:29as a rare event.
• 06:30Actually, exposure to trauma is quite common.
• 06:35Everything we know about trauma is that
• 06:37it occurs over the entire life course,
• 06:40but the type of trauma exposure varies with
• 06:43age and why this is important is because
• 06:46youth are disproportionately exposed to
• 06:48interpersonal violence and accidents,
• 06:50so these are age cumulative curves.
• 06:52So the way you read these is if
• 06:55you look at the yellow Vine that
• 06:58represents everyone in the population,
• 07:00and this is from the world mental
• 07:02health surveys who is exposed
• 07:04interpersonal violence?
• 07:05And then it looks of everyone exposed
• 07:08interpersonal violence by what time in
• 07:11their life was their first exposure,
• 07:13and you can see that for
• 07:16interpersonal violence.
• 07:18People who are going to get exposed
• 07:2060% or exposed before the age of 18,
• 07:22and you know,
• 07:23sort of similarly for accidents,
• 07:25while other events happen all over the
• 07:27entire life course and you don't have
• 07:29half the population exposed until about
• 07:31you know until close to middle age.
• 07:36And this is important for women
• 07:38because women and girls are more highly
• 07:41exposed to interpersonal violence,
• 07:42events and these events have the
• 07:45highest conditional risk for PTSD.
• 07:47So one of the things that sometimes people
• 07:50aren't aware about trauma is that we,
• 07:52when we look at sort of any traumatic event,
• 07:55men are actually in most studies.
• 07:57Men are more likely to experience any events,
• 08:00so we just have a list of events
• 08:02and say you experience any more
• 08:04mental actually endorsed that.
• 08:06But women are more likely to
• 08:08experience certain kinds events like
• 08:09for interpersonal violence events.
• 08:11Actually, an average man are
• 08:13usually consistently more likely
• 08:14to experience accidents.
• 08:16And this is important because these
• 08:18kinds of events have a higher conditional
• 08:21risk of PTSD, so this slide is.
• 08:23This was a it's a review article,
• 08:26sort of, with data compiled from a
• 08:28whole bunch of different studies,
• 08:31and the important part of this
• 08:33slide is that certain events,
• 08:35like accidents, are quite common,
• 08:37but the conditional risk of PTSD.
• 08:39The proportion of people
• 08:40exposed accidents develop.
• 08:42PTSD is on the lower side,
• 08:44it's usually around 10 to 20%.
• 08:46If you're looking at accidents that
• 08:48lead people to go to the emergency room,
• 08:51some more significant accidents.
• 08:53While something like rape the
• 08:55conditional risk of PTSD is about 50%.
• 08:59And the other thing we know is that recovery
• 09:02from PTSD actually is influenced by the
• 09:05type of event the person is exposed to,
• 09:07so these are also data from the world
• 09:10Mental Health Survey and you can see
• 09:12that PTSD related to violence is slower.
• 09:15The recovery from PTSD related to
• 09:17violence is slower than that for other
• 09:19traumatic event Caesar recovery curves,
• 09:21so you can see that the proportion of people
• 09:24still in Episode 4 war related trauma,
• 09:26physical violence, interpersonal violent.
• 09:28In our payment partners,
• 09:29sexual violence is higher,
• 09:31the recovery is slower than for other things,
• 09:34like for example.
• 09:35Again, accidents recovery is quicker,
• 09:37although I would note that
• 09:39everyone's recovery when they develop
• 09:41PTSD is not incredibly rapid,
• 09:43so we're looking at years here.
• 09:48The other thing we know from the world
• 09:50mental health about the importance of
• 09:53violence in terms of Women's Health and
• 09:55actually the population burden of PTSD,
• 09:58is that physical and sexual violence account.
• 10:00Are over half the PTSD burden
• 10:02in the US population and the way
• 10:04we look at this in the world,
• 10:06Mental Health surveys is we count the number
• 10:09of months of that of PTSD in the population.
• 10:11So if I have PTSD and I've had it
• 10:14for I have it for three months,
• 10:16and you have PTSD for two years.
• 10:18We count 24 months for you
• 10:20in three months for me.
• 10:21So when we look at the number of
• 10:24months of PTSD in the population.
• 10:27The largest proportion of those months can
• 10:29be attributed to events related to violence,
• 10:31and this is true.
• 10:32Actually we look in the
• 10:33surveys globally as well,
• 10:35although sometimes if you look at
• 10:36specific countries this this isn't true,
• 10:38but it is true in the US.
• 10:43So considering this,
• 10:44how do trauma and PTSD alters womenshealth
• 10:46trajectory's over the life course?
• 10:48And this is something that I got
• 10:50interested in actually way back in my
• 10:52training during Graduate School at BU,
• 10:54I worked at I did an internship
• 10:57or practicum at the Boston VA,
• 10:59which many of you may know in the
• 11:01Women's Health Sciences division and
• 11:03there I started seeing patients as
• 11:05my first patient with PTSD and I just
• 11:08notice that my patients with PTSD also
• 11:10had all these physical health problems
• 11:12and we're struggling with these.
• 11:14Chronic diseases and it was really
• 11:15from those experiences early in my
• 11:17training that I started wondering
• 11:19what's the relationship between
• 11:20these two and a clinical way.
• 11:21I could see how their mental health
• 11:23affected their physical health,
• 11:25but I thought you know what they
• 11:26have gotten sick anyway and it sort
• 11:28of really stimulated a whole bunch
• 11:30of questions that then years later
• 11:32I had the opportunity to follow up.
• 11:34In the nurses health study.
• 11:37So, um Dylan,
• 11:38mention the nurses health study,
• 11:40so it's a cohort of 100 and 16,000
• 11:42ish female nurses.
• 11:44They were recruited in 1989 and
• 11:46they've been followed.
• 11:47Since we're actually working on the
• 11:492021 questionnaire like this week.
• 11:51They were there now 55 to about 72
• 11:55years old and it's pretty white,
• 11:5895% Caucasian,
• 11:59which represents the sort of
• 12:01population of nurses at that time.
• 12:04And there followed with biennial by
• 12:06only questionnaires on diseases and
• 12:08health related lifestyle factors.
• 12:09The study was designed to look
• 12:11at environmental and behavioral
• 12:13factors in Women's Health.
• 12:14So the data is very good on those things
• 12:17and I've had the opportunity over the
• 12:20years to embed questions on mental health,
• 12:22stress,
• 12:23trauma,
• 12:23violence and PTSD within the cohort so we can
• 12:27look at the those factors and Women's Health.
• 12:29One of the strengths of the cohort
• 12:31is that the physical health outcomes
• 12:34like cardiovascular disease.
• 12:35Are based on medical record review,
• 12:37so LTC survey.
• 12:38Did they say oh I was diagnosed with
• 12:40diabetes or cardiovascular disease or lupus,
• 12:42then the cohort requests for medical
• 12:44records and they have positions.
• 12:46Review the medical records
• 12:47to verify the diagnosis.
• 12:49So there's a lot of benefits in
• 12:51working in the cohort and that
• 12:53I don't have to go through.
• 12:55Asking people you know, are you depressed?
• 12:57Have you experienced trauma or
• 12:58do you PTSD and do you have?
• 13:01I don't have to rely on self
• 13:04report for all the health data.
• 13:07So these are some new data
• 13:09these aren't published.
• 13:10We did a web survey as part of our
• 13:13grant on PTSD and accelerated aging,
• 13:15and I'll talk about some of the results.
• 13:18From that.
• 13:19We did a web survey that went
• 13:22out in 2018-2019.
• 13:23These are the responses to the
• 13:25survey before covid and you can see
• 13:28we this is based on about a sample
• 13:30about 32,000 women and these are the
• 13:33prevalence of different traumas reported.
• 13:36So you can see that these are.
• 13:39Again,
• 13:39this is probably a fairly
• 13:41homogeneous group of women
• 13:43who've at least at least had a nursing
• 13:46degree when they entered the cohort.
• 13:48You can see in this cohort,
• 13:50even despite their relative privilege,
• 13:52about 40% have experienced
• 13:54interpersonal violence,
• 13:55and you know a third report.
• 13:57About 20% report nursing related trauma,
• 14:00and then they also reported the
• 14:02whole range of other things,
• 14:04accidents or disasters.
• 14:08We also see that when we.
• 14:11Start my dogs coming in. Thank you.
• 14:16In the crack again, thank you.
• 14:18My dogs coming from work so we we also
• 14:21look at the age just as I mentioned
• 14:23the beginning from the world Mental
• 14:26health surveys that there's different
• 14:28points in the life where people
• 14:30are more likely to be exposed to
• 14:32different kinds of traumatic events.
• 14:34You can see here that in
• 14:36the nurses as well the age,
• 14:38the mean age of exposure to interpersonal
• 14:41sexual violence is much lower than,
• 14:43for example, Sonic or unexpected death.
• 14:45Although again people do
• 14:46experience these events.
• 14:48All over the life course.
• 14:51And so when we've been looking at
• 14:53trauma and PTSD in Women's Health,
• 14:55we've been looking at.
• 14:57Of course,
• 14:58our real goal is look at the
• 15:00health outcomes of disease,
• 15:01but we've been also looking at a
• 15:04number of different pathways to
• 15:05the disease and leveraging some
• 15:07of the strengths of the women
• 15:09of the nurses Health study,
• 15:10which is to look at behavioral
• 15:12factors and some biological
• 15:13factors as pathways to disease.
• 15:19So first looking at some of the
• 15:21behavioral factors, for example,
• 15:22we've shown that women who develop
• 15:24PTSD reduced their physical activity.
• 15:26So one of the strengths of the cohort is
• 15:28that we nestar measures within the collection
• 15:31of data on all these health behaviors,
• 15:33and so we can look at women before they are
• 15:36exposed to trauma or develop PTSD and C.
• 15:39Do we notice changes in their behaviors
• 15:41after they develop their exposed to trauma,
• 15:44develop PTSD? And you could see that,
• 15:46for example in this case.
• 15:48Before they develop trauma,
• 15:49for they are exposed to trauma, develop PTSD.
• 15:53There's really no difference between
• 15:55women on their physical activity,
• 15:57but after trauma,
• 15:58those who develop PTSD,
• 16:00their physical activity declines.
• 16:04In a somewhat more complicated picture,
• 16:06although it sort of corresponds to
• 16:08the physical activity, we can look
• 16:11at things like television viewing.
• 16:13So after exposure to trauma,
• 16:15the women who develop have
• 16:17the highest PTSD symptoms.
• 16:18We use us a screen in our in our
• 16:21questionnaire questionnaire survey,
• 16:23so the women who have the highest symptoms
• 16:26or her screen positive for PTSD four to
• 16:29five or above is screen positive are.
• 16:32Tend to increase their television viewing
• 16:35compared to women who experience trauma,
• 16:37but don't develop PTSD.
• 16:41And then not surprisingly,
• 16:42this then is manifested in
• 16:44things like body mass index.
• 16:46So when we looked over the life of the
• 16:49cohort, we found that PTSD at baseline
• 16:52was associated with higher BMI and
• 16:54a greater increase in BMI overtime.
• 16:57But probably like but more interesting
• 16:59was that we saw more rapid weight gain
• 17:02after PTSD onset then for those who were
• 17:04exposed to trauma and didn't develop PTSD.
• 17:07So similar to the figures I
• 17:09showed a couple slides ago.
• 17:11We can look at the slopes and weight
• 17:13gain before women are exposed to trauma,
• 17:16and then once they're exposed we can see
• 17:19that through the slope changes we made.
• 17:21Who developed PTSD versus those
• 17:23with Trump who don't.
• 17:25And it does.
• 17:26Women who develop PTSD tend to
• 17:28have more rapid weight gain.
• 17:34So 1 pathway by which trauma and PTSD affects
• 17:37health is through these behavioral factors.
• 17:40On the other one that we've been
• 17:44looking at most present one set of data.
• 17:47Here is pathways such as HPA access in Flint,
• 17:51inflammation, etc.
• 17:53So so for example, Jennifer Sumner,
• 17:56who was a postdoc with us in, is now at UCLA.
• 17:59She did work a lot of work on
• 18:01PTSD and inflammation,
• 18:03and looking in the cohort,
• 18:04so one of the other things that's
• 18:06embedded in the cohort is they
• 18:08have done blood samples overtime.
• 18:10And she showed that women with
• 18:12chronic PTSD tend to have these higher
• 18:15levels of inflammation measured
• 18:16by CRP or the TNF Alpha receptor,
• 18:19and that these tended to persist overtime.
• 18:22And these are in women,
• 18:23a disease free women were
• 18:25selected for disease free women,
• 18:27so inflammation could be another pathway
• 18:30by which traumatised influence disease.
• 18:33And then finally to look at disease outcomes.
• 18:36So we've,
• 18:37we've looked at our original work with,
• 18:39aiming to look at PTSD and
• 18:43risk of cardiovascular disease.
• 18:45And so we found that women with
• 18:48trauma an forkless symptoms of PTSD,
• 18:50which is the screen positive on
• 18:53our PTSD screen had increased risk
• 18:55of MI and stroke prospectively.
• 18:58But also have risk of a number
• 19:01of other outcomes.
• 19:02So for example,
• 19:03women with the highest PTSD symptoms had
• 19:07increased incidence of type 2 diabetes.
• 19:10Over the life of the cohort.
• 19:12As well as kind of more surprising to me,
• 19:16and I'm still quite.
• 19:18Like sceptical of?
• 19:20This of this this these findings,
• 19:23although they are very robust,
• 19:25everything we looked at more recently.
• 19:27We've been looking at trying PTSD
• 19:29and cancer and found that PTSD
• 19:32increases risk of ovarian cancer,
• 19:33and particularly the effect is really
• 19:35seen in the pre menopausal women.
• 19:38As you can see,
• 19:39the ends are very small incidents
• 19:42with varying cancer is is small,
• 19:44so you need a very large cohort
• 19:46to look at it,
• 19:48but we've kind of been digging into this.
• 19:51Actually found in PTSD and ovarian cancer.
• 19:55And then other outcomes such as
• 19:57hyperthyroid hyperthyroidism is
• 19:59associated with PTSD perspectively,
• 20:00so really we've found that trauma
• 20:03PTSD are associated with a pretty
• 20:06wide host of diseases.
• 20:07Other papers have looked at lupus,
• 20:10so it's not specific to
• 20:12cardiometabolic disease,
• 20:13which was the error that
• 20:15I was most interested in,
• 20:17but it really seems to have this wide.
• 20:21Association of My training Association.
• 20:24And not surprisingly,
• 20:25given this effect on chronic disease,
• 20:28we also find now that PTSD, trauma,
• 20:30and PTSD, especially competing,
• 20:32come depression when combined.
• 20:34So when it's comorbid,
• 20:35increased risk of early death in the cohort.
• 20:38So in this,
• 20:39in this analysis we found that women
• 20:42with high PTSD symptoms and probable
• 20:45depression had almost there was a 3.8 volts,
• 20:48almost a four fold greater risk
• 20:50of death in women without trauma,
• 20:53exposure or depression, and.
• 20:55I'm.
• 20:55This was this was somewhat explained by
• 20:58differences in behavioral risk factors,
• 21:00although not completely.
• 21:02Unfortunately,
• 21:02our cause of death data is
• 21:04incomplete, so this didn't seem
• 21:07to be totally explained by,
• 21:09for example, sudden death or suicide.
• 21:11But you know, are there
• 21:13records or someone incomplete,
• 21:15so we're hoping in the future
• 21:18we can look more cause of death.
• 21:22So the effects that we've seen entron
• 21:25PTSD on all these different diseases.
• 21:28How to start thinking about whether Truman
• 21:32PTSD accelerates aging in a broader way?
• 21:35Then we could capture by just looking
• 21:38at specific health conditions and
• 21:40also particularly in cognitive
• 21:42aging as these women get older.
• 21:48And part of this interest came from a pilot
• 21:51study we did in in a small sample from the
• 21:54cohort there were 116 women who had data
• 21:57on trauma and PTSD and telomere length,
• 22:00and we found that PTSD diagnosis was a show
• 22:04associated with shorter telomere length.
• 22:06Which is considered a marker of cellular
• 22:08aging, and so we decided to extend the
• 22:11work to see if PTSD was associated with
• 22:14a wider range of biomarkers of aging.
• 22:17So right now one of our studies
• 22:19is to look at, for example,
• 22:21PTSD and trauma and the epigenetic Clock.
• 22:24We have some broader analysis on telomere
• 22:26length and some other biomarkers of aging.
• 22:29A lot of that work actually has been held
• 22:32up due to Cobit and Doodle apps closing,
• 22:35but our cognitive.
• 22:36Data collection is still going,
• 22:38so we hopefully and maybe a six
• 22:40months or a year will have the other
• 22:42cellular data cellular marker data.
• 22:44Um, from our initial analysis,
• 22:46this is also not published at this.
• 22:48I think it just got this last week.
• 22:51We looked at a much bigger sample
• 22:53in the nurses health study about.
• 22:55I think this is 1800 women and
• 22:57looked at the relationship trauma,
• 23:00PTSD,
• 23:00depression and telomere length and
• 23:02what we found when we dug into the
• 23:05data that it's really the effect we
• 23:07see on telomere length is really
• 23:09the women in the women with high
• 23:11PTSD symptoms and depression.
• 23:13We see the shorter telomere length.
• 23:15And not in the other groups
• 23:17which you can see in this slide.
• 23:21So to talk about our cognitive data,
• 23:23so we've been collecting cognitive
• 23:25data in the cohort for a while now.
• 23:28Using the Cogstate brief battery,
• 23:29which I'm which I'll present a
• 23:31bit and happy to talk about.
• 23:32There's a lot of pros and cons to it,
• 23:35but one of the pros is
• 23:37that you can administer it.
• 23:38You know online which has been
• 23:41a huge advantage in Covid,
• 23:43an also a big advantage when
• 23:45you have a national cohort where
• 23:47doing you know in person testing
• 23:50is not going to be possible.
• 23:52So our Cox 8 brief battery has four tasks,
• 23:56two tasks to put that focus on
• 23:59psycho motor speed, inattention,
• 24:00and two on learning and working memory.
• 24:03And these tasks were were selected
• 24:06to be sensitive to changes overtime
• 24:09and particularly cognitive decline.
• 24:11And there's a lot of work out
• 24:13there with the Cox State battery.
• 24:15It's been around awhile.
• 24:16I think it was one of the first
• 24:19batteries that was done on line,
• 24:20so now there are many,
• 24:22many different batteries and some
• 24:23have advantages over Cox State.
• 24:25But what they found is that there
• 24:27was a robust relationship contagion.
• 24:29Cognitive functioning on this
• 24:30battery for each year of increasing
• 24:31age was associated significantly
• 24:33worse cognitive performance.
• 24:34So then these are the effects for
• 24:36Psycho motor speed and attention
• 24:37and learning and working memory.
• 24:42So to start with the Psycho motor speed,
• 24:45speed and attention. Battery tasks.
• 24:51So the this is the detection task and
• 24:53it measures processing speed using
• 24:55a simple reaction time paradigm.
• 24:57It on the instructions are have the
• 25:00card has the car turned over and
• 25:02a playing card is presented face
• 25:04down in the center of the screen,
• 25:07the card flips over so it's face
• 25:09up as soon as the card flips over,
• 25:12the participant must present yes.
• 25:14So is there such
• 25:15a thing as a retirement fund?
• 25:17Tord health expenses?
• 25:24Only some employees.
• 25:27Someone might not be muted.
• 25:29Sorry, I was confused.
• 25:31I thought so was asking me a question.
• 25:34Yeah no, just a reminder to mute
• 25:37your mute your computers if you're
• 25:40particular having other conversations.
• 25:42Thank you, thanks.
• 25:45OK man sorry and then they there's an
• 25:47identification task which measures attention.
• 25:49I'm using a choice reaction time
• 25:51paradigm in is it the question is is
• 25:53the card read and a playing card is
• 25:56presented in the center of the screen?
• 25:58The card flips over so it's face
• 26:00up and as soon as it flips over,
• 26:02the participant must decide
• 26:04if it's red or not.
• 26:05So it's a very simple task.
• 26:09And we found that elevated PTSD symptoms
• 26:12were associated with significantly worse
• 26:14performance in terms of psycho motor speed,
• 26:17an attention, and if you look over here,
• 26:20these are the results.
• 26:21After adjusting for both health behaviors,
• 26:24health conditions, health behaviors,
• 26:25health conditions and depression,
• 26:27and you see this effect.
• 26:30And then on the learning and working
• 26:33memory task we again there's 22 tasks.
• 26:36These are the.
• 26:37This is the first task.
• 26:39Is this one card learning task which
• 26:41measures visual memory and the question is,
• 26:44have you seen this card before this test?
• 26:47A playing card is presented based
• 26:49up in the center of the screen and
• 26:51the participants decide whether
• 26:53they have seen the card before.
• 26:55In the past they might have seen it in
• 26:58the other tasks that I just presented,
• 27:01and then there is a one back task which
• 27:04the instructions are as a previous card,
• 27:06the same and a playing card
• 27:08is presented face.
• 27:09Up in the center of the screen and the person
• 27:11participants decide if they've seen it.
• 27:13If it's the same as the previous card.
• 27:17And they said yes.
• 27:18If it's the same and now it's not so again,
• 27:21it's it very simple task.
• 27:23And what we've found is elevated PTSD
• 27:25symptoms were associated with significantly
• 27:27worse learning and working memory.
• 27:30You see here and if we look at
• 27:32what the the mean difference to
• 27:35see get a sense of affect site.
• 27:37The mean difference for four to
• 27:40seven PTSD symptoms versus no PTSD
• 27:42was for that of four years of aging.
• 27:49And so, um. Moving on these so we
• 27:54see these effects of trumpetist EON.
• 27:56Women's Health behavior is health and
• 27:59then also on this cognitive aging,
• 28:01and we're collecting more data and more
• 28:03longitudinal data on cognitive aging,
• 28:05so I will have better data on that
• 28:08and hopefully in the next year.
• 28:11But we've also seen the adverse effects
• 28:14of trauma and PTSD across generations.
• 28:17Um, so our first study on this week
• 28:19I got interested in this because
• 28:22having been worked in working in
• 28:25the trauma field for a while,
• 28:27there were a lot of studies which
• 28:30had looked at, for example, Rachel,
• 28:32who does work on Holocaust survivors
• 28:34or there's work on refugees.
• 28:36So work on moms and children
• 28:39were on families.
• 28:40An really severely traumatized
• 28:42populations which showed relationships
• 28:44between parental and offspring PTSD.
• 28:46Um and we wanted to see in
• 28:48the nurses Health study,
• 28:49which is sort of a more community
• 28:51sort of typical civilian population.
• 28:53Whether we saw some of the same
• 28:56relationships and we did so,
• 28:57we basically took it with.
• 28:59This was an opportunistic.
• 29:00We were going along imbedding trauma
• 29:03and PTSD measures in the nurses study.
• 29:05Meanwhile,
• 29:05there's another study called the
• 29:07growing Up Today study which
• 29:09is children of the nurses.
• 29:11That was set up and folks who led that
• 29:13study put some of the same measures
• 29:16that we did in the moms in the kids,
• 29:18and so the kids were separately
• 29:20assessed for trauma and PTSD,
• 29:22as well as all the other
• 29:24things are assessed for.
• 29:25In sort of laid out lessons,
• 29:27early adulthood for the first time.
• 29:29So Andrea Roberts,
• 29:30who works with me on a lot of this,
• 29:33had the idea of looking at PTSD in
• 29:35the moms and see how that related
• 29:38to trauma in the children and what
• 29:40we found was that children and
• 29:42mothers with PTSD were exposed
• 29:44to more traumatic events,
• 29:45and that this was true even when
• 29:47we took out any events that could
• 29:49possibly have been shared between them.
• 29:51You know,
• 29:52such as like a house fire or something.
• 29:56And then, not surprisingly,
• 29:57children of mothers with PTSD were
• 30:00more likely to have also have
• 30:03PTSD themselves,
• 30:03and this didn't seem to be totally explained
• 30:08by differences in exposure to trauma.
• 30:11When this became an so
• 30:13I mean I study genetics,
• 30:14PTSD,
• 30:15so this isn't really wasn't
• 30:17really surprising to me when this
• 30:19became sort of more interesting
• 30:21is when we extended the timeline
• 30:23and we decided to look at trauma
• 30:25that occur due to mothers before
• 30:28their child would have been born.
• 30:30So we looked at maternal childhood trauma.
• 30:33An outcomes in the kids,
• 30:35and particularly outcomes
• 30:36beyond mental health outcomes.
• 30:38So I'll just present a little of that.
• 30:41So, for example,
• 30:42we looked at maternal experience
• 30:44of childhood abuse, which was this.
• 30:47This variable is a combination of sexual,
• 30:50physical and emotional abuse.
• 30:51So we looked at children of mothers
• 30:54who were abused and we found that
• 30:57maternal abuse was for example
• 31:00related to smoking and offspring.
• 31:02And it was sort of remarkable about this
• 31:04was this is actually also the case in
• 31:07children of mom to wear non smokers.
• 31:09So it wasn't. Entirely of course,
• 31:12mothers smoking played a
• 31:14part in this the level of.
• 31:17Smoking in this court is actually a
• 31:19little lower than the population level,
• 31:20and even if we look at the
• 31:23month we didn't smoke.
• 31:24Kids up of moms who had severe who were
• 31:27in the severe abuse category were more
• 31:29likely to initiate smoking early and
• 31:32maintain high levels of consumption.
• 31:34And then also they were they
• 31:36were more likely to, for example,
• 31:38to have higher BMI's and higher
• 31:39risk weight trajectory's.
• 31:41So the children and moms who
• 31:43are abused had higher BMI.
• 31:44Sort of pretty consistently overtime.
• 31:46And if you look at this more severe,
• 31:48moderate abuse.
• 31:49Fine, but then what was striking
• 31:51is when these kids got older.
• 31:53So and actually at the time
• 31:55they'd mostly be leaving home.
• 31:57They also had these higher risk weight
• 31:59trajectories where they were gaining
• 32:01weight more rapidly and this again
• 32:02was also not explained by maternal.
• 32:04Be in mind,
• 32:05which is something we actually have
• 32:07very good data for in the nurses.
• 32:13So that got so that is doesn't work there.
• 32:15And then we've been doing a lot
• 32:17of other stuff in that area.
• 32:19I can talk about.
• 32:20Andrea Roberts has pursued
• 32:22is really leading that work.
• 32:23But before I move to move on to like
• 32:26the sort of 2nd part of the talk,
• 32:28which I'll talk a little bit more.
• 32:30So what do we do about this?
• 32:33And we see all these negative effects
• 32:35of PTSD etc over the life course.
• 32:37I did want to mention I did want to
• 32:39mention a little bit of work that we're
• 32:42doing that was motivated by this work.
• 32:44On the effects of maternal
• 32:46experience of stress and trauma and
• 32:49the health effects of offspring.
• 32:51So I had the opportunity during
• 32:53Covid to join a group out of
• 32:56something called registry,
• 32:57which is a sort of social media
• 33:00platform for to connect pregnant
• 33:02and postpartum women with health
• 33:04information to do a mental health
• 33:07and stress survey of women pregnant
• 33:09or recently postpartum during covid.
• 33:11So this was the survey it was launched in.
• 33:16What was that May in June of 2020?
• 33:20Um, we controlled about 7500 women globally.
• 33:22There were 68 countries represented,
• 33:25about 30 two countries,
• 33:26with over 100 participants,
• 33:28and this is again,
• 33:29this is a social media platform,
• 33:32so it's not a representative survey,
• 33:34so there's sort of disproportionately
• 33:36more highly educated group more
• 33:39likely with partner,
• 33:40and we had about 25% who identified it.
• 33:43Healthcare or essential workers,
• 33:45and they're not young,
• 33:46particularly young moms.
• 33:48It could be 18 or above to join, but.
• 33:51The mean age was 31.
• 33:53So,
• 33:54um.
• 33:54It's interesting the result when you
• 33:56take into account that on average
• 33:58these are probably sort of better off
• 34:01women than is typical in the population,
• 34:03so I'll just present a little
• 34:05of this experience during kovit
• 34:07since we're still living with it,
• 34:09so this is represents this is
• 34:11where the participants were from,
• 34:12so you can get a sense of what
• 34:15countries were represented.
• 34:17Um?
• 34:21And. OK, some things going on in my porch,
• 34:26but so as part of the survey we had
• 34:28a bunch of questionnaires on stress
• 34:30and depression and anxiety and PTSD
• 34:32and I'll present some of that data,
• 34:34but we also had comment boxes where women
• 34:36could write in and say you know anything
• 34:38they want to tell us about their experience.
• 34:41So this is just some of the
• 34:43things that women shared.
• 34:44I had preeclampsia.
• 34:45I think it would have been detected
• 34:47sooner if I wouldn't have had to
• 34:49cancel a doctors appointment.
• 34:51I'm feeling depressed because
• 34:52of unemployment.
• 34:52Financially, my family is struggling.
• 34:54It seems like Corona is going to
• 34:56make our lives more difficult.
• 34:57I'm worried about my upcoming baby.
• 34:59I feel like this is the end of the world,
• 35:02the whole birth experience
• 35:04was mentally devastating.
• 35:05And I'm scared for my children
• 35:06ability to care for my children.
• 35:08I can't breastfeed.
• 35:09I'm worried about my husband gets it.
• 35:11I'm worried that I'll get sick
• 35:13and leave my kids alone and you
• 35:15can see some of the other things.
• 35:17Other things I thought went
• 35:18for an important and I'm,
• 35:19you know I'm scared and up and
• 35:21praying at night so women really
• 35:23feeling isolated and lonely really.
• 35:24Women really shared a lot in these.
• 35:26I'm not a qualitative researcher,
• 35:28but in these comment boxes they
• 35:29really showed a lot of their
• 35:31experiences and was really striking.
• 35:32Is that you know through this platform again,
• 35:35these.
• 35:35Women who connected with this
• 35:37on social media.
• 35:38How how similar their experiences were,
• 35:40whether they were writing from
• 35:42Mexico or China or the US,
• 35:44which were the three countries
• 35:47we had the highest numbers from.
• 35:50So just to give a flavor of what
• 35:53women reported experiencing.
• 35:54So these women who participate
• 35:56in our survey had really reported
• 35:58really significantly high anxiety,
• 36:00depression, and PTSD.
• 36:02You can see that over 40% met
• 36:04we use the impact of N scale 6,
• 36:08which is a brief measure of PTSD
• 36:11that has been used in a lot of,
• 36:14but we adapted it for covid.
• 36:16So this is covid related PTSD.
• 36:19We adapted it from.
• 36:20It's been used in a lot of other epidemics,
• 36:24epidemics globally,
• 36:25and we compare that to meta analysis
• 36:28of PERI and postpartum women pre covid.
• 36:31So this meta analysis results that
• 36:33were out in the literature and then
• 36:36at the time the general population.
• 36:39And data that was come out in Covid.
• 36:42So again, it's not representative sample,
• 36:44but at least the woman responded.
• 36:46The Surveyor really reporting high levels,
• 36:48anxiety, depression and PTSD,
• 36:49so we'll be following this,
• 36:51but did want to share something of our code.
• 36:54Would work.
• 36:57So I realize I painted a pretty dismal
• 36:59experience, a dismal picture here,
• 37:01with the high levels of exposure to trauma,
• 37:04PTSD,
• 37:04and then the effects over the life course.
• 37:07So I do did want to in the last
• 37:09part of this talk talk about what
• 37:12we can do about it,
• 37:13and one of the things that
• 37:15we're learning is that
• 37:16effectively treating PTSD may attenuate
• 37:18the adverse effects of trauma and
• 37:20physical health, so that is just.
• 37:23You know those of us in mental health know
• 37:27that we can effectively treat PTSD in many
• 37:31cases and reduce people suffering and.
• 37:34What's becoming interesting is that
• 37:36that those those treatments that
• 37:39may that affect people's mental
• 37:40health may also have some long-term
• 37:43benefit on their physical health.
• 37:45So we got interested in this and have been
• 37:48trying to model this in our observation.
• 37:50ULL data which is all the
• 37:52limitations of observational data.
• 37:53But because we have this
• 37:54long little to no cohort,
• 37:56we can look at questions such as.
• 37:59You know it doesn't matter.
• 38:00The data presented earlier with
• 38:01the people at women had PTSD.
• 38:03They already creased risk,
• 38:05for example for cardiovascular disease.
• 38:06But then we can look more carefully in
• 38:09the Cohen say doesn't matter if their
• 38:12PTSD is severe and ongoing or if it's.
• 38:15Ramets at some point and as remission
• 38:17of PTSD also result in attenuation of
• 38:20the risk for cardiovascular disease.
• 38:22And we can see that it does so.
• 38:25In this slide they just show that
• 38:27severe ongoing PTSD symptoms is
• 38:29associated with increased risk
• 38:31of cardiovascular disease,
• 38:32which is similar to what I showed
• 38:35in the earlier earlier slide.
• 38:37But the difference here is we took
• 38:39out people with the women whose
• 38:42whose moderate severe PTSD symptoms
• 38:44remitted an their risk.
• 38:46For CVD West attenuated.
• 38:49And there's a number of studies.
• 38:52The other work that I'm aware of in this.
• 38:55That's this.
• 38:55The observational work is inviere data.
• 38:57So for example, there's a study by Berg
• 39:00which looked at treatment and PTSD in VA,
• 39:03electronic health records,
• 39:04and what they found was PTSD was
• 39:06associated with increased for
• 39:08hypertension and the records.
• 39:09But that treatment did attenuate the
• 39:11effect of PTSD and risk for hypertension.
• 39:14In this case they were able to
• 39:16actually define treatment in a
• 39:18way I think that's reasonable.
• 39:20Treatment included either 8 individual
• 39:22psychotherapy sessions are 50 minutes
• 39:24or longer during a consecutive six
• 39:26months or a prescription for SSR eyes
• 39:29which is or medications that are
• 39:31indicated for the treatment of PTSD.
• 39:33So they you know they had limitations and
• 39:35how they could define treatment as well,
• 39:38but with their sort of treatment defined
• 39:41better than we can in our cohort.
• 39:43They did find this attenuation of
• 39:45risk of on the relation between PTSD
• 39:48and hypertension with treatment.
• 39:50So I think there's lots of opportunities
• 39:53for here for going forward,
• 39:55particularly potentially with
• 39:56treatment studies of PTSD.
• 39:58Whether they could look at down the line,
• 40:01whether this treatment in attenuates
• 40:04the health implications of PTSD.
• 40:07But one of the challenges is that most
• 40:10people with PTSD don't receive any
• 40:12health treat any mental health treatment.
• 40:14So these are data from the World
• 40:17Mental health surveys,
• 40:18and so this is data from people who
• 40:21met criteria for PTSD in the survey,
• 40:23so they had diagnosed PTSD and even
• 40:26among people diagnosed PTSD in high
• 40:28income countries only about a third
• 40:30reported specialty mental health treatment.
• 40:33And that doesn't even differentiate
• 40:35whether this was any kind of good
• 40:37mental health treatment or not.
• 40:39And in the nurses health study cohort,
• 40:42we've asked now about treatment,
• 40:44and it's about half of the women who have.
• 40:48Diagnosed PTSD.
• 40:49Meet all the criteria for diagnosis.
• 40:53And we would consider it chronic.
• 40:55Only about half of them have received
• 40:58any specialty mental health treatment.
• 41:01And what's sad about this is that
• 41:03there are effective for PTSD and
• 41:05effective treatments for PTSD.
• 41:07The 3rd edition of effective
• 41:09treatments for PTSD,
• 41:10I think just came out in 2020.
• 41:13And so in these treatments have
• 41:16been pretty widely disseminated
• 41:18in getting the VA system,
• 41:20but I think less so in the
• 41:24general population.
• 41:25And so to close I'm just going to
• 41:28talk about one of the treatments
• 41:30that I've been involved in as.
• 41:33Is that and how that works and its
• 41:35implications in terms of thinking about
• 41:38Women's Health and development and PTSD.
• 41:40So one of the treatments that is in
• 41:43the effective treatments PTSD book
• 41:44is that maybe less widely known and
• 41:47prolonged exposure or cognitive
• 41:49processing therapy is sterope E which
• 41:51is a treatment that was developed
• 41:54originally by Marilyn Cloitre and to
• 41:56treat adult survivors of childhood
• 41:58abuse and sense.
• 41:59Then in the second edition,
• 42:01which is here which came out just last year.
• 42:05Has been extended to people with
• 42:07any kind of interpersonal
• 42:09trauma, but she's as well as well
• 42:11done it with other populations
• 42:13being including, for example,
• 42:15first responders, things like that.
• 42:19And this is based on,
• 42:21I mean trauma treatment that are
• 42:23the ones that are widely known.
• 42:26The one that I was training which is
• 42:29prolonged exposure are based on cognitive
• 42:31behavioral models of trauma of trauma.
• 42:34So for example,
• 42:35exposure therapies based primarily on
• 42:37PTSD as a conditioned fear response
• 42:39resolved by repeated imagine or even
• 42:42vivo exposure and or cognitive therapy
• 42:44like cognitive processing therapy,
• 42:46where which is focused on
• 42:48trauma related cognitions.
• 42:50Which are maladaptive and recovery
• 42:52involves reappraisal adjustment of
• 42:54these beliefs and sterope stair include
• 42:57some of these aspects of both of these.
• 43:00But it's it's based more on a
• 43:02resource last model of trauma which
• 43:04comes from its origins in treating
• 43:06adult survivors of childhood abuse,
• 43:08and that is trauma is an experience
• 43:11of resource loss,
• 43:12where trauma results in the loss
• 43:14of social resources such as the
• 43:16sense of connection to others and
• 43:18emotional resources is the ability
• 43:20to identify and manage emotions and
• 43:22the loss of identity lost of mastery,
• 43:25competency and goodness.
• 43:26And you can see that this extends
• 43:28to all kinds of trauma beyond
• 43:30childhood abuse and something that.
• 43:32Maybe many of us can relate to our people
• 43:35or relate to in the lives of people we know.
• 43:38Given all the losses people have
• 43:41experienced through computer Kobe.
• 43:43Stair narrative therapy is 18 sessions.
• 43:46The first part,
• 43:47start focuses on skills,
• 43:49training and emotional regulation
• 43:51and interpersonal skills,
• 43:52and the second part is more traditional
• 43:55exposure therapy with account,
• 43:57which is basically a modified form of
• 44:01prolonged exposure and meaning making.
• 44:04And there's lots of.
• 44:06There's been RCT's with stair this is leader,
• 44:09some list some below and I'm
• 44:12happy to share my slides and as
• 44:15well as the effect size is forced
• 44:18air versus treatment as usual.
• 44:20But it's it's evidence based,
• 44:22and I think this in the
• 44:25comparison to prolonged exposure.
• 44:26It sort of was equivalent.
• 44:30And so,
• 44:31just to give a little more detail on
• 44:33scare before I close the first part,
• 44:36this.
• 44:37These are the components of the first part.
• 44:39You can see with a big chunk of
• 44:42the first part,
• 44:43focusing on emotional awareness
• 44:45and naming feelings,
• 44:46understanding how feelings affect your body,
• 44:48your mind in behavior and then learning
• 44:51emotional regulation skills in the service
• 44:53of goals that you value in your life.
• 44:55And then the second part is around connecting
• 44:58so understanding relationship patterns.
• 45:00And how those have been
• 45:01influenced by your trauma,
• 45:03history and then how you can develop
• 45:06flexibility in relationships.
• 45:07And then once did after those are
• 45:09the sort of idea of stair is that in
• 45:13certain populations of trauma survivors,
• 45:15so skills need to be enhanced
• 45:17before you can go on to focus
• 45:19on their trauma experience.
• 45:21So in narrative therapy it is
• 45:23combination of narrating the traumatic
• 45:25experience and making meaning out of it.
• 45:28And it does work like sort of a tradition.
• 45:31More traditional exposure therapy that
• 45:33many people might be familiar with.
• 45:35I think the one difference.
• 45:37From the way I was trained originally
• 45:39was that it's also sort of.
• 45:42It really looks at the trauma story,
• 45:44and in lysis schemas and how
• 45:46those influence people's
• 45:47behavior in their current life.
• 45:52So I mentioned some of this,
• 45:54but I'm happy to answer questions about this,
• 45:57so I think steer is different than
• 45:59other empirically based therapies,
• 46:01in that it does have the skills
• 46:03training component before
• 46:04doing the trauma focused work,
• 46:06and so it does have this very present
• 46:08day component of of building skills
• 46:10that help people in their current
• 46:12lives and connecting the trauma to
• 46:14their B2 behaviors in current life.
• 46:16And it's different for then DBT.
• 46:18For example an that it was
• 46:20created for trauma patients.
• 46:22And it's it's a shorter duration individual.
• 46:25There's also a group format,
• 46:26and it's focused on improving functioning.
• 46:29It's not as focused on
• 46:31life threatening behaviors.
• 46:33Um and I would say there's there's.
• 46:35There's real differences in sort of the
• 46:38patients they are oriented towards.
• 46:40DBT usually focuses on patients who
• 46:42are really high risk for injuries
• 46:44and self in suicidal behaviors.
• 46:46Although Stair has a lot of
• 46:48components of DBT,
• 46:50it is a shorter and sort of
• 46:53less wrap around treatment.
• 46:55And during Covid I wasn't developing
• 46:57problem development of this,
• 46:59but Marilyn,
• 47:00her team did develop a web version
• 47:02for Telemental Health web version
• 47:05of Stair which is available now.
• 47:07I know it's being used in the VA
• 47:10and they have a project to work
• 47:13with specially rural Villiers using
• 47:15Webster and there also exist aircoach
• 47:18that people can check out if there
• 47:21interested people in clinical work or.
• 47:24Just interested, it's available,
• 47:26you know, by your App Store.
• 47:29And so if folks are interested
• 47:31in learning more about Stair,
• 47:33here's the information that's
• 47:35available through the NC&C.
• 47:37PTSD website.
• 47:41So I will end there.
• 47:43I'm happy to answer any questions.
• 47:45Just want to acknowledge all the
• 47:48different people who worked on
• 47:50many of the studies I presented.
• 47:51Especially highlight Andrea
• 47:53Roberts who has been working
• 47:55with me on this since like 2008,
• 47:57as well as all my students who
• 47:59who have many have gone out but
• 48:02who contributed to the work.
• 48:04The work presented as well as
• 48:07acknowledge all my funders cluding NIH,
• 48:09and also the funders for the
• 48:12Nurses health study and the WHL
• 48:14World Mental Health Surveys.
• 48:19And finally, I always like
• 48:20this is where I usually finish.
• 48:22My life was like to acknowledge
• 48:24all of the people out there.
• 48:26The advocacy organizations and
• 48:27those who are who you know,
• 48:29really spend their lives focused
• 48:31on preventing trauma and violence,
• 48:32which would really be.
• 48:35In the first place,
• 48:36to put our efforts in order to prevent
• 48:39all these negative mental health
• 48:40and physical health consequences,
• 48:42both to women and people.
• 48:44Generally an across generations.
• 48:46And then finally,
• 48:48because I can't do a talk on trauma
• 48:51and stress without acknowledging that
• 48:53we are in covid and I want to just.
• 48:57Thank you everyone for taking time today.
• 48:59I'm sure people's lives are really
• 49:01crazy and also acknowledge all the
• 49:02over 2 million people have died of
• 49:04covid and their friends and family
• 49:06members who are grieving actually
• 49:07used the slide not that long ago
• 49:09and I had to increase the number of
• 49:12people who died double it so it's.
• 49:15Heard that we're still living
• 49:16through this and.
• 49:19That's my contact information and again,
• 49:23happy to share my slides,
• 49:25answer any questions and.
• 49:28Thank you very much and I will stop sharing.
• 49:32Thank you. Now I see their
• 49:34stuff in the chat and I didn't.
• 49:37OK, good thank you.
• 49:39So yeah, happy to answer questions.
• 49:41I see there's some questions I didn't.
• 49:42I didn't look at the chat like I was talking,
• 49:45so let me see if there's anything to me.
• 49:50So I see one question in the weather
• 49:54101 question in the chat which is
• 49:58related to whether I see the effects in.
• 50:02Attacks I'm observing in people who.
• 50:06Don't remember who had amnesia
• 50:08after childhood trauma.
• 50:10Then recall more as adults in my work.
• 50:14That is a good question,
• 50:15so we only have women in our cohort.
• 50:18We are assessing we are following
• 50:20women in adulthood, so we rely on
• 50:22their reports of childhood abuse.
• 50:23So I actually don't really in
• 50:25the types of studies I do,
• 50:27we don't really have people who've.
• 50:29We don't have people with documented
• 50:31abuse histories who then forgot, or,
• 50:33you know, don't don't remember it,
• 50:35so I can't really answer.
• 50:37That question I think the best work
• 50:39on that is Kathy Williams work,
• 50:42where she followed a cohort of
• 50:44kids who had documented abuse
• 50:46histories and then actually ask them
• 50:49about their abuse and you have.
• 50:51She actually does analysis of
• 50:53women have people, men, women who.
• 50:56Forgot their abuse,
• 50:57which are very interesting and
• 51:00actually quite complicated.
• 51:02So I would encourage you to look at her work.
• 51:06OK, more questions, can you?
• 51:10Yes, so good question from Frank.
• 51:13So yeah, comment on the generalizability
• 51:16of the nurses registry so.
• 51:19Yeah, Interestingly,
• 51:20I think so in a couple of ways.
• 51:23One is they are they are,
• 51:25you know, sort of.
• 51:28You know more educated abit more
• 51:31if you look at the population
• 51:34they look at women from the ages
• 51:37in the US from 55 to 70 mid 70s
• 51:40they are going to be somewhat more
• 51:42educated so somewhat higher SES.
• 51:44So there's quite a bit of diversity.
• 51:47Again, 95% white.
• 51:50And so they're sort of.
• 51:52A bit more bad,
• 51:53a bit better off in a bit healthier.
• 51:56They probably have lower smoking
• 51:58and although they look pretty
• 51:59normal with exercise in obese,
• 52:01like the general population
• 52:02with many health respecters,
• 52:03they are probably a little
• 52:05bit on the healthier side.
• 52:06Maybe sort of like UK biobank is.
• 52:11At the same time,
• 52:12they report a lot of trauma,
• 52:15so in particularly in the latest survey,
• 52:17the Ocelot about occupational trauma like
• 52:20things they had witnessed as a nurse,
• 52:22and they reported really high levels
• 52:24and a lot of distress related to that.
• 52:28So I think.
• 52:29In some ways,
• 52:31they're an interesting counterpoint
• 52:32to the to the veteran population,
• 52:34which is, you know, different,
• 52:36so there are different in
• 52:37their sort of better off,
• 52:39but there's ways in which,
• 52:41from their lease their self
• 52:42reports of trauma, they look more.
• 52:45Stressed an impact it then you might expect.
• 52:51OK. Symptom clusters, oh, OK.
• 52:55Or a lot of Frank OK exposed to yes.
• 52:59Yes I would say yeah,
• 53:01they're they're exposed to.
• 53:03Pretty chronically exposed.
• 53:05They also they report pretty high levels
• 53:08of having experienced child abuse too.
• 53:10So I think that is true that they are.
• 53:12They don't just have one
• 53:14or two in defects, traumas.
• 53:15In terms of differences in PTSD
• 53:17prevalence or outcome by race ethnicity,
• 53:20which is another question.
• 53:23We can't really look at that in
• 53:25the nurses because of our small
• 53:27proportion of nonwhite nurses
• 53:29and other studies I have done.
• 53:31In general population surveys we
• 53:34have found differences in exposure
• 53:36to trauma and PTSD by race ethnicity.
• 53:38Um, the sort of summary of that is certain.
• 53:44Minority populations black.
• 53:47And Native American and.
• 53:52Tend to have report higher
• 53:54incidence of exposure to violence,
• 53:56particular interpersonal violence.
• 53:57And because of that,
• 53:59higher prevalence of PTSD.
• 54:02Um, with lower prevalence is
• 54:04reported in certain Asian groups
• 54:07and but that somewhat depends on.
• 54:10The origin of the different groups,
• 54:11so we still are some differences there,
• 54:13for example between Mexican Americans
• 54:15in Puerto Rican's or an Asian groups,
• 54:17whether they originate from serve,
• 54:18for example like.
• 54:19Vietnam or from China.
• 54:21So there are some differences,
• 54:23but in the nurses cohort we
• 54:25can't look at that.
• 54:29Jefferson City um?
• 54:36K. Um can help
• 54:39you with the question.
• 54:43I'm having trouble going through.
• 54:45Yeah, they're starting to pile up,
• 54:47so I'll try and read them as you answer.
• 54:51Now. Have you compared your
• 54:52data on ethnic minorities,
• 54:54non dominant groups versus ethnic majorities?
• 54:56Dominant groups in different countries?
• 54:58Is that data available to you?
• 55:01That's a good question, um.
• 55:06You know I mentioned the one
• 55:08study we did in the US in the
• 55:10world Mental health surveys I'm,
• 55:12I'm thinking I I'm not.
• 55:14I have not been involved in a study.
• 55:16Have done that.
• 55:17There's a lot of work in those surveys,
• 55:20and I don't recall,
• 55:21and I don't know how available it is.
• 55:24One of the challenges in the world
• 55:26Mental Health surveys is that their
• 55:29general population surveys so thus.
• 55:31At best you get,
• 55:32you get the representation of
• 55:34different groups at whatever they
• 55:36are in the population so often.
• 55:39That makes it difficult
• 55:40unless you oversample.
• 55:42And minority group and Ethnic minority group.
• 55:45You don't end up getting enough
• 55:47people in the different groups
• 55:49who participate and then also the
• 55:51other challenge with the kind of
• 55:54population based work is that,
• 55:56especially if there's no
• 55:58ethnic tension or other.
• 56:00Issues within a country.
• 56:02The ethnic minority group is probably even
• 56:04less likely to participate in the survey.
• 56:06So so basically the answer is is no.
• 56:09Not in my work and other people's work.
• 56:11For example,
• 56:12an in some of the studies that have
• 56:15been done on PTSD and some of the
• 56:17different African countries I've
• 56:19worked in there have been there has
• 56:21been work on higher levels of trauma
• 56:23experience in certain ethnic minority
• 56:25groups and higher levels of PTSD.
• 56:29But there's limited data on it.
• 56:32OK, we find that peripheral inflammation
• 56:35markers are associated with evidence
• 56:37of suppression of neuroinflammation.
• 56:39And in both PET scans in postmortem tissue,
• 56:43are you aware of any clinical signatures
• 56:48of immunosuppression infections
• 56:50or tumors associated with PTSD?
• 56:52That's from Doctor Crystal course. Thanks
• 56:56John. Extending my.
• 57:00I.
• 57:04So I actually I.
• 57:07Someone one of the people I I mentioned,
• 57:11Andrew is doing an analysis in a
• 57:14subsample of of the nurses related
• 57:17to an extension of this cancer work.
• 57:20I presented and he is looking at.
• 57:24Um? Tumors in specific type of tumor.
• 57:27So I may have something on you
• 57:29I can get back to you on that,
• 57:31so not off the top of my head,
• 57:34but I believe they're looking at
• 57:35it and I can't remain remember
• 57:37exactly if they are far enough
• 57:38along to know what they found,
• 57:40but it would be.
• 57:41I think it would be possible to
• 57:44look at that in the nurses data.
• 57:46If they haven't because of the
• 57:48amount of information they do have
• 57:50an an those factors the focus of
• 57:52the nurses has been their husband.
• 57:54A lot on cancer.
• 57:55An I mean it's oppression and infection.
• 57:57Things like that that hasn't been
• 57:58linked to the mental health stuff yet,
• 58:01so that would be really interesting.
• 58:04Doctor Jordan, do you want to ask
• 58:07your question before I'll be quick.
• 58:09Thank you so much for your talk.
• 58:12I really enjoyed it. Thank you.
• 58:14Are there and I appreciate you bringing
• 58:17awareness to the trauma of experiencing
• 58:19so many deaths with COVID-19 and I
• 58:22think I just respectfully take a
• 58:24step further and just say how it has
• 58:27impacted minoritized communities
• 58:28even more because of structural
• 58:30racism and a disproportionate rates
• 58:32up death and morbidity.
• 58:34That's kind of where my question lies,
• 58:37because I've been thinking about as a
• 58:41minoritized person more and more kind of
• 58:44the ongoing vicarious trauma experienced.
• 58:47Through just kind of being in this country,
• 58:50but definitely what we've been seeing in
• 58:53terms of social media platforms in the
• 58:56sharing more more of police brutality,
• 58:59violence, killing, you know thinking about.
• 59:01Obviously, Brianna Taylor.
• 59:02George Floyd on my Arbury very
• 59:05present in our consciousness.
• 59:07And so my question is.
• 59:10How do we think about that in the
• 59:13context of PTSD, how do we study that?
• 59:16There was a wonderful scholar, Doctor,
• 59:18Lawanda Hill that talked about really there.
• 59:21Being no post period for Minoritized books
• 59:23because you're just constantly in this.
• 59:26Prime State waiting for the next trauma,
• 59:29right?
• 59:29And so there's some work I know.
• 59:32Really wonderful,
• 59:33burgeoning young neuroscientist Aza
• 59:35from our group that's looking at this.
• 59:39On a molecular level,
• 59:40but I'm trying to understand like
• 59:42how do you think about this?
• 59:43How do you approach it?
• 59:44I don't think that we can use our.
• 59:47Regular kind of paradigm in
• 59:49terms of studying the post,
• 59:51because there's really no posts an
• 59:53if you're able to kind of lead,
• 59:56give me some thoughts.
• 59:57Yeah,
• 59:58sure,
• 59:58it also provides some folks
• 01:00:00who are doing this work that
• 01:00:02would be really helpful. Sure, absolutely.
• 01:00:05So I think you hit on the big challenge is.
• 01:00:10Is that that the whole concept and not
• 01:00:13let it historically that kind of how PTSD
• 01:00:16has been defined is related to trauma
• 01:00:18XDA Post traumatic stress disorder.
• 01:00:21So traumas happen and even if they were,
• 01:00:23chronic trauma such as having combat
• 01:00:26in Vietnam, let's say things that
• 01:00:28happened overtime, the person was safe.
• 01:00:30And then we're still having these symptoms,
• 01:00:33and I think that's exactly what you hit on.
• 01:00:36And it's actually a challenge
• 01:00:38for the entire field.
• 01:00:40And how we as you even even define
• 01:00:43the language about what is and
• 01:00:45who decides what is traumatic,
• 01:00:47for whom, and how we define trauma.
• 01:00:50And then this whole issue of post.
• 01:00:53So that's just to say I think you have
• 01:00:56framed the issue that is challenging the
• 01:00:59entire field in the field has not really,
• 01:01:02greatly, you know,
• 01:01:03grappled with that.
• 01:01:04And I will say that in our I didn't present
• 01:01:08these in our Global Pregnancy survey,
• 01:01:10we did ask questions about.
• 01:01:12Experiences of racism and discrimination,
• 01:01:15which were sort of like really
• 01:01:18astronomically associated with the
• 01:01:19mental health outcomes that we presented.
• 01:01:22And it's a little challenging to present
• 01:01:26these data because this is global, so how?
• 01:01:29How discrimination and race is
• 01:01:31defined differs by country,
• 01:01:32so it gets kind of complex to present it.
• 01:01:34So that's just to say.
• 01:01:36Technology in and I think is there are.
• 01:01:41A number of different people in the
• 01:01:44field that are doing work on this.
• 01:01:47I think we did a population health session
• 01:01:50on which I can share in the chat on
• 01:01:54racism as a as a traumatic event at Harvard,
• 01:01:57which had a number of speakers so I can.
• 01:02:01I'm happy if you want to.
• 01:02:05The email me I can connect you with them
• 01:02:08so you could look at their different
• 01:02:11work and see which would be best.
• 01:02:14Like you know,
• 01:02:15most most may be relevant to the work.
• 01:02:17You are doing, but I think that I don't.
• 01:02:20I wish I had an easy answer for it,
• 01:02:23but I don't.
• 01:02:24I think it's a challenge for the entire
• 01:02:26field and the traditional measures
• 01:02:28we use on trauma don't include.
• 01:02:30I mean,
• 01:02:30they actually don't even include
• 01:02:32sexual harassment,
• 01:02:33let alone anything on racism
• 01:02:34or structural racism,
• 01:02:35and that those assessments have developed.
• 01:02:38They shouldn't just almost separately,
• 01:02:40and I do think that we need to
• 01:02:42bring the two things together.
• 01:02:44Yeah,
• 01:02:44no,
• 01:02:44I I appreciate that and I think it's good to.
• 01:02:48That the field, at least his wrestling
• 01:02:50with it and realizing that that is
• 01:02:52a major shortcoming, right right?
• 01:02:54You can't make any meaningful
• 01:02:55conclusions if we're not even.
• 01:02:56I'm asking about it for
• 01:02:58sure. Yeah, right?
• 01:02:59And the one of the people.
• 01:03:00One of my colleagues work
• 01:03:02that I really like on this.
• 01:03:04Says Alex Tsai at MGH.
• 01:03:05He did a paper that was in The Lancet,
• 01:03:08I think. Sort of time is a little bit.
• 01:03:12Big in my head this last year,
• 01:03:15but on which is on, for example,
• 01:03:17police shootings and mental health.
• 01:03:19And what was really powerful about
• 01:03:22his paper was not just focused on,
• 01:03:24I mean the shooting and
• 01:03:26the individuals involved,
• 01:03:27but how it affected.
• 01:03:30Population mental health.
• 01:03:32For example,
• 01:03:33Blacks and whites in the United States,
• 01:03:35and it's a complex analysis 'cause
• 01:03:38it looks at shootings and media
• 01:03:40reports and data and population
• 01:03:42based mental health data.
• 01:03:44But I think that has a lot to contribute.
• 01:03:47And then the other person who we
• 01:03:50have had we've been talking to
• 01:03:52the most is Jessica Lopresti,
• 01:03:55who is in at Suffolk,
• 01:03:57and her work is really excellent.
• 01:03:59I mean, she's she's she's.
• 01:04:01She's young, she's an assistant professor,
• 01:04:03but I think in terms of work.
• 01:04:05Looking at framing racism and
• 01:04:07discrimination as a trauma.
• 01:04:09Her work is really excellent,
• 01:04:11so those are like two of the people,
• 01:04:13but there's like there's obviously many.
• 01:04:15So yeah,
• 01:04:16thanks.
• 01:04:16Thank
• 01:04:17you, you're welcome.
• 01:04:17Yeah, you have a question
• 01:04:19from Doctor Missouri.
• 01:04:20Have you examined sex differences
• 01:04:22in PTSD trauma occurrence?
• 01:04:23If so, do you find similar
• 01:04:25different findings in terms of
• 01:04:27adverse effects in children?
• 01:04:30That is, yeah, that's a great question,
• 01:04:32so I can say so yes, I've done some work
• 01:04:36on sex differences, so in terms of.
• 01:04:40The in our in our in our specific data.
• 01:04:43Looking at the effects of maternal trauma,
• 01:04:45an offspring we actually just say
• 01:04:47we don't find big sex differences,
• 01:04:49so the whether it's a male or
• 01:04:51female offspring of the mother who's
• 01:04:53experienced trauma we don't find,
• 01:04:55I we won't find big sex references,
• 01:04:57which is why I didn't.
• 01:04:58You know, present them,
• 01:05:00and in fact even looking at outcomes
• 01:05:02like 80 HD Andrew Robertson,
• 01:05:04some work on maternal moms,
• 01:05:05experience of childhood abuse and
• 01:05:07increased risk of ADHD in offspring.
• 01:05:09And there wasn't a different sex effect,
• 01:05:11even though obviously there's a
• 01:05:13sex difference in ADHD. So, um.
• 01:05:17In our sort of observation,
• 01:05:19ull work we don't. Separately there is some.
• 01:05:22This is debated,
• 01:05:24but there are some some interesting
• 01:05:26work from the from the genetics point
• 01:05:29of view on the that some studies have
• 01:05:32found differences in heritability
• 01:05:34of PTSD between men and women.
• 01:05:37How much that is explained by
• 01:05:40differences in that end set the men
• 01:05:42have PTSD tend to be for military
• 01:05:46samples versus women.
• 01:05:47Is Filion we don't know.
• 01:05:49So in some ways I've been really
• 01:05:51interested in sex differences.
• 01:05:53Mainly because when I saw patients
• 01:05:55I observed big sex differences in.
• 01:05:57I felt like the expression of PTSD,
• 01:05:59but we haven't seen again,
• 01:06:01at least in these sort of FB observation.
• 01:06:04ULL studies we haven't seen big differences.
• 01:06:11More questions.
• 01:06:16OK.
• 01:06:19Other questions I should jump on here.
• 01:06:22If you have a question that
• 01:06:24hasn't been addressed,
• 01:06:25you can unmute yourself and just
• 01:06:26jump in. If you 'cause I want to.
• 01:06:32Hi. I wanted to ask about
• 01:06:36the the control for the.
• 01:06:39Groups where you saw the patients
• 01:06:42with PTSD having increased BMI
• 01:06:45and then the impact on
• 01:06:47cardiovascular and inflammatory
• 01:06:49markers, and I was wondering,
• 01:06:51is this related to the BMI
• 01:06:54or is it related to PTSD?
• 01:06:57It seems like the the biggest.
• 01:07:01Different your
• 01:07:02data was showing that the PTSD is
• 01:07:05causing the the weight gain. But
• 01:07:09then the the. Impact of weight gain on the.
• 01:07:15Give a score and inflammation
• 01:07:16is might be the reason.
• 01:07:18Might be the actually the the weight
• 01:07:21again right? Yeah so we look at that an if.
• 01:07:26And when we model it,
• 01:07:27there's you know some proportion of the
• 01:07:30weather it's heart disease or diabetes,
• 01:07:32for example, is explained by weight
• 01:07:34gain and other factors like that,
• 01:07:36like health behaviors, but not the majority.
• 01:07:38An actually in the diabetes paper.
• 01:07:40The most surprising finding was so.
• 01:07:42So I think weight gain,
• 01:07:44if I'm remembering correctly,
• 01:07:45the way to explain it.
• 01:07:47It was a good chunk.
• 01:07:49It was like 30 to 40% of the effect
• 01:07:52you know is a big chunk of the effect.
• 01:07:56But actually, antidepressants explained
• 01:07:57the biggest proportion of the relation
• 01:08:00between PTSD and type 2 diabetes.
• 01:08:02And I remember this so clearly
• 01:08:04because of course,
• 01:08:05that's what the media lot jumped
• 01:08:07on after the paper was published.
• 01:08:10But yeah, I'm actually surprised at the
• 01:08:13health behaviors doesn't explain more.
• 01:08:16Honestly,
• 01:08:16that's what I would have expected.
• 01:08:17I thought it would all be explained
• 01:08:19by health behaviors an it's not and we
• 01:08:21actually have very good health behavior data.
• 01:08:23I mean,
• 01:08:23you can always have better data,
• 01:08:25but that's one thing I feel like we have
• 01:08:27quite good data 'cause we ask people
• 01:08:29regularly about their health behaviors.
• 01:08:30So yeah,
• 01:08:31it's interesting.
• 01:08:31And So what are the other things going on?
• 01:08:34And that's a good.
• 01:08:35That's yeah,
• 01:08:36that's I'm curious about that.
• 01:08:38Thank you.
• 01:08:45OK, great hearing and seeing
• 01:08:47no more questions and thank you
• 01:08:49very much Carsten that was great.
• 01:08:52Welcome, that was fun.
• 01:08:54Thank you all for attending.
• 01:08:57Yes, an as I said I'll maybe I'll
• 01:09:00send Trish the slides in case anyone
• 01:09:03wants the slides or just email me.
• 01:09:05I put my email, I could
• 01:09:08put my email in the chat,
• 01:09:10but if you have follow up questions
• 01:09:13or something I said like like the
• 01:09:15mention that paper by Alex I or
• 01:09:18Jessica like Jessica Lopresti,
• 01:09:20I am happy to just just ping
• 01:09:22me and I will direct you.