Yale Psychiatry Grand Rounds: January 29, 2021

January 29, 2021

Information

"Trauma and Women's Health: Within and Across Generations"

Karestan Koenen, PhD, Professor of Psychiatric Epidemiology, Harvard T.H. Chan School of Public Health.

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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.