Allostatic Load:  Beneath the skin interrupting the pathways to pathology
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Allostatic Load: Beneath the skin interrupting the pathways to pathology



This slideshow explores the way that stress leads to biological pathology. It attempts to connect the adverse childhood events study with Bruce McEwen's work on cortisol and stress.

This slideshow explores the way that stress leads to biological pathology. It attempts to connect the adverse childhood events study with Bruce McEwen's work on cortisol and stress.



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Allostatic Load:  Beneath the skin interrupting the pathways to pathology Allostatic Load: Beneath the skin interrupting the pathways to pathology Presentation Transcript

  • Beneath The Skin Interrupting the pathways to pathology Presented by: Michael Changaris, Psy.D.
  • Goals for today  Understand current research on childhood adversity and resilience in health.  Know the common pathways that lead from childhood adversity to pathology.  Recognize some biological markers that lead to childhood adversity transitioning disease and early death.  Begin to develop clinical tools to address impacts of childhood adversity in our patients.
  • Environmental Changes Biological Differences Rat Study – Generational Impacts of Adversity
  • Aces Study “When a house is burning down you do not see the flames you see the smoke. If you do not know the relationship between smoke and fire one might think that smoke was the problem and bring a fan and blow the smoke away.” - Dr. Felitti
  • Public Health Crisis Scope of the Childhood Adversity  More then 5.5 million children likely effected by child abuse each year (child abuse reports).  More then 16.6 million Children below the poverty line (2010).  1.5 milion Children have parents in jail.  Prenatal impacts of domestic assault, maternal stress, socioeconomic stress are endemic.
  • The Brain of a Severely Neglected Child Can Be 38% smaller with an IQ = 50 half of typical IQ =100
  • ACEs Smoking and COPD
  • Aces and Autoimmunity  Sixty-four percent reported at least one ACE.  34.4 men and 31.4 women out of 10,000 (first hospitalization from any autoimmune disease).  First hospitalizations for any autoimmune disease increased with increasing number of ACEs.  People with 2+ ACEs: ◦ Th1 had 70% increased risk of hospitalization compared to those with no ACEs ◦ Th 2 had 80% increased risk for hospitalizations ◦ 100% increased risk for rheumatic diseases. * All p values reported at .05
  • ACEs and IV Drug Use
  • Behavior is the Largest Predictor of Health
  • Developing Resiliency  Positive Family Relationships  School attachment  Neighbor support  Peer support/Social support  Religiosity  Academic Achievement  Emotional support outside the family  Positive Self-regard  Spirituality  Inner-directed locus of control  Family closeness  Cognitive Coping Stratigies/Emotion Regulation
  • Pathways – Adversity to Pathology Behavior, Social Functioning and Biochemical Changes
  • The Pathways to Pathology 3 Key Factors 1. Difficulty w/ Behavioral Regulation Leading to Adverse Health Behaviors. 2. Poor Social Support 3. Changes in Biological Systems
  • Childhood Adversity Effects the Ability to Make Effective Health Decisions
  • Changes in Biological Systems
  • Social Support – Health Outcomes  Loneliness is highly related to all cause mortality and is significant risk factor for health outcomes.  Lack of social support effects: ◦ Poor Self-Concept ◦ Emotional responses and ability to regulate emotions ◦ Problem solving – attempting to solve life's problems with out the advice, support or mentorship of others (e.g. you have to make all the mistakes yourself) ◦ Effects multiple biological systems from cortisol to insulin
  • Social Isolation
  • Good Social Connection
  • Environmental Changes Biological Differences Rat Study – Agouti Gene and Epigenetics
  • Beneath the Skin Biology and Adversity
  • Alostatic Load…
  • Bruce McEwen, PhD Stress Researcher
  • Pathological Adaptation
  • Systemic Dysregulation and Disease Processes
  • Allostatic Load Index
  • Allostasis and Health  Higher allostatic load scores associated with: ◦ Poorer cognitive fxn. ◦ Physical functioning. ◦ Predicted larger decrements in cognitive and physical functioning. ◦ Increased risk for the incidence of cardiovascular disease  Allostatic Load predicted these outcomes independent of sociodemographic and health status risk factors. Seeman, Teresa E., et al. "Price of adaptation: allostatic load and its health consequences: MacArthur studies of successful aging." Archives of internal medicine 157.19 (1997): 2259-2268.
  • Bottom Up Top Down1. Regulated Sleep Cycles 2. Healthy Diet 3. Cortisol 4. Circulation 5. Pain Management 6. Exercise 7. Increased Healthy Psychological Coping 8. Social Support 9. Meaning/Purpose 1. Glucose Metabolism 2. Blood Pressure 3. Triglycerides Cholesterol 4. Telomeres/Telom erase 5. Apoptic Factors (e.g. Capsase 8 & 9, Bcl2-alpha, Bax etc.) 6. Inflammation (d- dimer, TNF-a, N-Nos, IL1, IL6 etc.)
  • Dysregulation and Disease
  • Team Based Care
  • Importance of Treatment Teams  Increased continuety of care.  Defined roles can lead to effective collaboration and improved patient outcomes.  Increased job satisfaction and reduced burn out.  Address health complexity, patient defined goals and support the patient to be an active participant in health.
  • Building Health Teams  Five key factors: Trust, Communication, Commitment, Accountability and Results.  Create role clarity, pathways for communication, and point person for health goals.  Culture of a profession can develop a culture of interprofessionalism.  Clean house. Deal with challenges to team care openly and quickly.
  • Adverse Childhood Events High Stress Depression PTSD GAD Poor Social Support Poor Sleep Increased Inflammatory Cytokines Hip to Waist Ratio High Low SES Poor Coping Skills Elevated Cortisol Psychotherapy Increased Control at Work Lower Life Stress Reduced Pain Healthy Diet Physical Exercise Statins, NSAIDs Increased Emotion Regulation Increased Sleep: CBT, Trazadone, CPAP etc. Increased Social SupportMassage Touch Therapy Chocolate Yoga Thai Chi Increased Stress Management and Coping Skills SSRI/SNRI/S DRI
  • Patient Centered Biopsychosocial Care Planning  Patient Driven Health Goals? – Developed in collaboration w/ PCP and health team.  Creating Continuity of Care? – Identifying gaps in treatment, adherence problems, follow through, stressors (ABC – Antecedent, Behavior, Consequence).  Building Care Team? – Who is on the team? Defined by the best way to support PT to reach health goals. Defining roles.  Incremental Implementation? – Do enough but not too much. Support PT to develop new tx goals as previous goals are accomplished.
  • Case Discussion  32 yr-old Caucasian Woman  Homeless 1 yr  Substance abuse hx, Bipolar II dx  Insomnia  Current depression impacting tx adherence and decision making.  Physical abuse by spouse and parents.  Hyperlypidemia  HTN  Migraines poorly controlled  Chronic pain LB and Legs  Poor Medication adherence due to life stress, financial stress & relational chaos.