Transcript The psychological journey through a woman’s lifecycle

The Earthquake Assessment
©
(Sichel & Driscoll, 1999)
Jeanne Watson Driscoll, PhD, APRN, BC
October 5, 2007
Women’s Health: Addiction, Trauma & HOPE
Princeton, New Jersey
Objectives
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Discuss the concepts of allostasis and
allostatic loading
Describe The Earthquake Assessment Model
(© Sichel & Driscoll, 1999)
List the key questions in each assessment
domain
Discuss the integrated assessment and
formulation of diagnosis and treatment plan
The Female Brain
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Different metabolism of medications
15% greater blood flow in brain:
serotonin system more reactive
Differences across the menstrual cycle
Drug interactions
Exclusion from drug studies
Structure/Function Differences
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Corpus Callosum: 23% larger
(Gorsky &
Allen)
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Language area 30% larger (Harasty)
Paralimbic Cortex more active (Gur & Gur)
Facial recognition easier (Gur & Gur)
Allostasis
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The history
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Cannon: homeostasis
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Role of feedback mechanism to reduce
variability and maintain constancy
Failed regulation-antecedent to illness
General Systems theory
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Dynamic non-linear process
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Seyle (1956)
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General adaptation syndrome
Proposed that chronic stress may have an
accumulative damaging effect on
physiology
McEwen
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Allostasis and allostatic loading
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Physiological health appears to be a
function of both the classical concepts
of homeostasis and more recent
understandings of the complex network
integrity and non-linear interactions
Defining feature of healthy functioning:
adaptive capacity to respond to
unpredictable stimuli and stressors
Stress
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Perceptions or actual experiences of
environmental demands (either internal
or external) that tax or exceed and
individual’s ability to cope ( Lazarus &
Folkman, 1984).
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The loss of that variability is proposed
as the generic feature of pathological
dynamics that precede morbidity and
aging
The social environment exerts
cumulative impact on the physical and
mental well being
Allostasis (McEwen, 1998)
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A concept that describes the
relationship between
psychoneurohormonal responses to
stress and physical and psychological
manifestations of health and illness
Allostasis
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(Bruce McEwen)
Allostasis is the process of achieving stability
through change
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Capacity to adapt to changing environments or
stressful challenges
Allows the organism to cope physiologically,
behaviorally, and emotionally with specific
environmental challenges while maintaining
regulatory control of the homeostatic systems that
operate within narrow parameters
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There are significant links between
molecular physiological systems,
structures and functions of the brain,
emotional interpretation and coping
capabilities
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Stress is subjectively defined and presents
with individual variations
Powerful predictors of stress activation are
individual expectations and interpretation of
events (McEwen,2000)
Within limits, allostatic response is adaptive
but when it occurs in excess of effective
coping capabilities, such responses result in
physiological overload
Structures
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Hippocampus-pituitary-adrenal axis
(HPA)
Autonomic Nervous System (ANS)
Immune system (inflammatory
cytokines)
Adrenal Cortex (glucocorticoids)
Adrenal Medulla (adrenalin)
“Brain Strain”
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(Sichel & Driscoll, 1999)
Allostatic Loading (McEwen)
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Accumulation of wear and tear on the brain
and the body, especially the hippocampus,
from the adaptive process
Individual interpretations of reality play a
pivotal role in eliciting physiological and
behavioral responses to challenges
Allostatic Loading
Wear and tear:
Situations associated with
allostatic load
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Frequent stress
Adaptation to
repeated stressors
of the same type,
resulting in the
prolonged exposure
of the body to the
stress hormones
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Inability to shut
allostatic responses
after the stress is
terminated
Inadequate
responses from
some allostatic
systems trigger
compensation in
others
Implications for human society
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Consideration of allostatic loading
important in the diagnosis and
treatment of many illnesses
Reduce allostatic load through coping
skills, recognition of limitations and
relaxation skills implemented
Decline in estrogen secretion increases
the activity of the HPA Axis in women
The brain in distress
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Does not feel pain
Distress is interpreted through signs
and symptoms
Mood, anxiety, and physical symptoms
are demonstrated
Stress
Hormones
Brain
Reproductive
Hormones
Neurotransmitters
genetics
Symptoms:
Psychological
Physical
Key vulnerable
times in a woman’s life
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Menarche
Premenstrual
Pregnancy
Infertility
Postpartum
Perimenopause
Menopause
The Earthquake Assessment
(Sichel & Driscoll, 1999)
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Metaphor to describe “allostatic loading”
and the impact on brain biology
Definitions
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Fault lines: biochemical brain
Tremors: sub-clinical symptoms
Earthquake: major psychiatric episode
Assessment areas: genetics; life events;
and reproductive events
Critical Assessment Domains
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Genetic/family history
Live events/Life stressors and reactions
Reproductive events and reactions
Assessment Process
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Establish rapport
Describe the process of collecting data
Remember, the woman is “living” the
experience, pay attention to your own
projections, assumptions, and
interpretations!
Assessment Questions
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Genetic History
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Any family history of mood/anxiety
problems? Diagnosed or not?
Any family history of substance use/abuse
What was it like living with your mother?
Father? Siblings?
Any extremes of mood
Did you ever feel scared?
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Did you Mother experience any
mood/anxiety problems around
reproductive events?
Any one been on any psychiatric
medications? (give names)
Life Events/Stressors
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Chronological Ages
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Any significant times in your life that you
felt sad/blue? Weight changes? Sleep
problems?
History of sexual/physical/emotional
abuse?
Alcohol/drug use
Reproductive Hormonal Events
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Onset of first period?
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Any hx. of mood/anxiety prior
Any hx. of migraine h/a, stomach aches,
physiological disturbances?
Oral/depot contraceptive history
Pregnancy history
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Number of pregnancies
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Any abortions/miscarriages
If positive pregnancy history:
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Describe how you felt your first trimester?
second? Third?
Describe the labor onset, process, birth
Describe initial day after birth
Describe postpartum experience
Any infertility experiences?
Adoption experiences
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Menstrual history
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Regularity, duration, etc.
Hx. of PMS/PMDD
Perimenopausal issues
Menopausal status
History of HRT/ERT?
Hx. of thyroid problems?
The brain that you were born with is
NOT the brain you have today!
Formulation
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Based on presenting signs and
symptoms
Unique to the individual woman’s
experience
Be alert to her “perceptive reality”
Develop care plan
The NURSE Program
(1999)
Developed by
Deborah Sichel, M.D. &
Jeanne Watson Driscoll, PhD,APRN, BC
The NURSE Program
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Nourishment and Needs
Understanding
Rest and Relaxation
Spirituality
Exercise
Nourishment and Needs
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Foods for the brain/body
Medications for the brain/body
Vitamin: Calcium, A, D, E, Omega 3’s
Eliminate alcohol and caffeine
Emotional needs
Understanding
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You are a human being and deserve
care
Use your cortical skills
Feelings, emotions, thoughts
Psychotherapy; journal keeping;
bibliotherapy
Groups for support, education, etc.
Rest and Relaxation
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Sleep: key assessment area
Sleep rituals: Develop a sleep hygiene
program
Power naps
Meditation, visualization, mindfulness
Yoga, stress reduction strategies
Spirituality
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Spirituality versus Organized religion
Uplifting, meaningful experiences
Relationships: with self and others
Appreciation for nature
Belief in a higher power
Nourishment for the soul
Exercise
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Find an exercise that you enjoy and do it!
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e.g. walking, swimming, running, gardening
“break a sweat”
No more excuses
Exercise cause the secretion of endorphins
which act on the brain in a positive way
Take care of your brain and it
will take care of you!
Select Bibliography
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McEwen, B. (2002). The end of stress as we know it.
Washington,DC: Joseph Henry Press.
Sichel, D. & Driscoll, JW (2000) Women’s moods.
New York: Quill.
Beck, CT & Driscoll, JW (2006). Postpartum mood
and anxiety disorders: A clinician’s guide.Sudbury,
MA: Jones & Bartlett Publishers.
Driscoll, JW (2005). Recognizing Women’s Common
Mental Health Problems: The Earthquake Assessment
Model. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 34, 246-254.
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McEwen, B (1998). Protective and damaging
effects of stress mediators. New England
Journal of Medicine, 338, 171-179
McEwen, B (2000). Allostasis and allostatic
load: Implications for
neuropsychopharmacology.
Neuropsychopharmacology, 22, 108-124.
McEwen, B (2005). Stressed or stressed out:
What is the difference? Journal of Psychiatry
and Neuroscience, 30, 315-318.
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McEwen, B.S. (2000). The neurobiology of
stress: from serendipity to clinical relavance.
Brain Research, 886,172-189.
McEwen, B.S. (2002), Sex, stress and the
hippocampus: Allostasis, allostatic load and
the aging process.Neurobiology of aging,
23:921-939.
McEwen, B.S. (2003) Interacting mediators of
allostasis and allostatic load: towards an
understanding of resilience in
aging.Metabolism, 52, 10-16.
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McEwen, BS & Wingfield, JC (2003).
The concept of allostasis in biology and
biomedicine. Hormones and Behavior,
43, 2-15.
Lazarus, R & Folkman, S. (1984).
Stress, appraisal, and coping.
NY:Springer.