"A word in earnest is as good as a speech"
~Charles Dickens: Bleak House

Monday, June 16, 2014

Medical Monday ..... Childhood Trauma, Epigenetics & Lupus

World Lupus Day
As I mentioned previously I began a graduate program in mental health counseling. I took a life-span development course last semester. The most interesting thing I have learned is that we have finally been able to end the argument of nature vs. nurture. The reality is both impact our development. You can be born with certain genetic traits and your environment can change them. As my professor said (and I am paraphrasing badly) - Your genetics you are born with, your epigenetics are up to you.

So, how do epigenetics work? In the most basic of terms, they are tags on your genetic code that turn on or off how your genes are expressed, your phenotype in a sense, and unlike your genetic code, these tags can be influenced by your environment. So what does that mean? My understanding (and please feel free to tell me if I am incorrect) is that if you smoke, or eat poorly, or are exposed to chemicals, your basic genetic make-up can be altered. It also means, that if you are raised in a traumatic or stressful household, your genetic make-up can be altered.

It is almost as if your DNA builds you as if you are going to live in a best case scenario. If your genetic make-up is never interfered with you will turn out a certain way, but if you live in less than ideal conditions, things may need to be altered to address that.

Gene therapy is based on this idea and some great strides have been made in the treatment of such diseases as Leukemia. So, I wrote my final paper on the connection between early childhood trauma, epigenetics and lupus. At the time I wrote the paper I could not find any conclusive research that showed a direct causal link between the three. I did however find lots of studies that indicated more study needed to be done. There are also indications that gene therapy could be the Holy Grail of Lupus treatment as well. 

Childhood Trauma, Epigenetics & Lupus
Leann Baldwin

Much research has connected childhood sexual abuse with psychological disorders such as depression, self-mutilation, suicidal ideation, personality disorders, substance abuse and post-traumatic stress disorder (PTSD) (Putnam & Trickett, 2006). Studies have also looked at how exposure to traumatic events (either in childhood or adulthood) impact overall health (Flett, Kazantzid, Long, MacDonald & Millar, 2002). Other studies have generally concluded that women with histories of childhood sexual or physical abuse are more likely to attempt suicide or have anxiety disorders than women with no such history (Heim & Memeroff, 2001). Several studies looked at the impact of childhood and cumulative stress on the epigenetics of autoimmune disease (Dube et al., 2009; Stojanovich & Marisavljevich, 2008; Stojanovich, 2010). For this paper I will review research in these different areas and see where there is overlap and where we can make hypothesizes for further study.

According to the 2011 Child Maltreatment report by the United States Department of Health and Human Services, 676,569 children were victims of maltreatment and of those 467,820 were reported for the first time. In Massachusetts alone, 14.4% of the child population (or 20,262 children) were victims of maltreatment. Nationally, 9.6% of maltreated children are sexually abused before the age of 17. With the relatively new discovery of epigenetics it has become more important than ever to determine what impact, if any, childhood trauma and neglect have on determining future health risks for these children.

The Role of Childhood Trauma in Adult Health
A 2002 New Zealand study explored the impact of trauma on physical health by interviewing 1,500 individuals from urban and rural populations in their homes (Flett, Kazantzid, Long, MacDonald & Millar, 2002). Trauma was defined as falling into 12 specific categories which included among other things childhood sexual assault and adult sexual assault; these were then grouped into three categories: crime, hazard and accident. Participants were asked specific questions about their history of trauma and their health; then participants completed the Pennebaker Inventory of Lumbic Languidness (PILL) to measure current health concerns (Flett et al., 2002).  This study concluded that individuals exposed to crime (particularly in childhood) had poorer health as defined by their current health problems. There was no indication that these individuals had a greater risk of chronic health concerns, such as SLE (Flett, et al., 2002). The limitations of this study were that they compressed many of the trauma categories, such as sexual assault, domestic violence and robbery into one category of crime. Because the results were generalized to crime we can’t use it to conclude that childhood sexual assault has an impact on even short term health risks.

While it is true that our DeoxyriboNucleic Acid (DNA) is determined at birth, early traumatic experiences can turn on or off certain genetic traits and create stable phenotypes that are susceptible to certain diseases. Studies indicate that these phenotypes can be altered and shaped by external stress factors, which in turn induce physiological responses which create “further stress exposure” (Heim & Memeroff, 2001).  Heim and Memeroff (2001) explored studies dealing with the impact of stress on both rodents and children in an attempt to determine if there is a “stable phenotype of altered stress vulnerability.” They determined that there are many factors in humans that determine how and if early childhood stress will manifest itself in biological traits or psychopathology. They found that in both humans and rats early childhood stress created permanent changes in the corticotrop-in-releasing factor (CRF) neurotransmission, which in turn impacts the central nervous system making people more susceptible to psychiatric disorders, immune disorders and ongoing stress exposure. More studies need to be done to determine how different stressors at critical stages of development alter CRF so that more effective treatments can be determined. The authors recommend longitudinal twin studies for the future of this research as a way to better isolate the phenotype alterations (Heim & Memeroff, 2001).

Longitudinal studies have been done that show early childhood abuse impacts the health of children as they develop, where one traumatic exposure doubles the risk of poor childhood health and three exposures triple the risk of poor childhood health (Sachs-Ericsson, Medley, Kendall-Tackett & Taylor, 2011). Further studies indicate that trauma and risky behaviors used as coping mechanisms, such as drug use, smoking and alcohol use, increase the risk of poor health in early adulthood (Sachs-Ericsson, et al., 2011). Does this risk to overall health extend into middle and late adulthood; and can we separate the risky behavior to isolate the abuse as the cause of increased health risks? Positive self-efficacy has been shown to have a positive impact on adult health and the ability to deal with illness; “there is evidence of an association between indices of self-efficacy and childhood abuse such that abuse has been shown to negatively influence one’s cognitions about the self” (Sachs-Ericsson, et al., 2011). It is therefore a reasonable hypothesis that by looking self-efficacy in older adults who were victims of childhood abuse, we may begin to answer this question. A study that interviewed 1396 individuals over the age of 50 concluded that individuals who reported abuse (either physical, sexual or emotional) in childhood had lower self-efficacy. They also showed that individuals, who reported child abuse and lower self-efficacy were more likely to be disabled, suffer from diabetes, have chronic headaches or have bladder issues. What this study was not able to do was determine if the health issues were due to changes to neurobiology caused by the abuse or the continued risky behavior used as a coping mechanism to deal with the abuse (Sachs-Ericsson, et al., 2011).

These previous studies suggest that early childhood abuse and stress can influence one’s health in both the short and long term. Through alterations in our phenotype, our perception of ourselves and risky coping mechanisms we can reduce the quality of health we live with. This has serious implications for how we treat childhood trauma, not only do we need to heal the child’s psyche, we must also take more care to look for increasing health concerns and intervene to lessen the risk of serious health complications in adulthood. If we don’t, the victims of childhood abuse will become revictimized by their own body.

Epigenetics and Autoimmune Disease
“Epigenetics refers to changes in the DNA or surrounding chromatin that influences gene expression, but that do not change genetic composition” (Zouali, 2011). Studies of monozygotic twins have shown that factors beyond heredity, such as diet and lifestyle, impact a person’s gene expression (Ballestar, Esteller & Rishardson, 2006; Zouali, 2011). How do these changes in our phenotype influence a diagnosis of Lupus? Studies looking at the impact of epigenetic changes over time and their impact on SLE focus on DNA Methylation, B-cell modifications and T-cell modifications. The combination of these help to regulate a person’s immune system: DNA Methylation helps to suppress foreign particles from our environment, including viruses that accumulate in our bodies over time; while the T cells regulate our immune systems response and direct B cells to produce antigens to fight infection (NIH, 2008).

Zouali (2011) has studied how environmental factors such as air pollution, polycyclic aromatic hydrocarbons (PAH), cigarette smoke and certain drug combinations impact the epigenetics of our immune response in a negative way, making people more susceptible to autoimmune illness. Environmental factors change gene expression in a way that the body is unable to identify and fight against infection and can cause the immune system to actually harm its host. He has concluded that we can go back as far as “ … in utero exposure to epigenetic modifiers” (Zouali, 2011) to determine susceptibility. While Zouali (2011) acknowledges that “deciphering the precise contribution of epigenetic factors to autoimmunity, and in particular to SLE, is in its infancy,” he concludes that the role of epigenetics in the delivery of human immune response is critical. Other studies have gone beyond Zouali concluding that epigenetics can not only help us to determine an individual’s predisposition to autoimmunity, but also may be the key to successful treatment of the diseases and perhaps one day a cure (Ballestar, Esteller & Rishardson, 2006).

While Heim and Memeroff looked at the impact of childhood stress on overall health, Stojanovich and Marisavljevich have looked at how general stress contributes specifically to autoimmune disease. “… The stress system orchestrated the responses of the body and of the brain to the environment” (Stojanovich & Marisavljevich, 2008), meaning that cells remain dormant until a stressor (which could be good or bad) activates the cell; the cell either adapts to the situation in a healthy way or a negative way (Stojanovich, 2010). Previous studies had concluded that patients who suffer from PTSD are more likely to have elevated T-cell lymphocytes and lower levels of cortisol, both of which are primary indicators of autoimmune disease (Stojanovich & Marisavljevich, 2008).  Patients with many autoimmune disorders are symptomatic in flairs, according to Stojanovich (2010) stress is the primary trigger for symptomatic flairs in patients with SLE and Rheumatoid Arthritis (RA); more so than other environmental factors or family history. These studies explored how chronic stress can be one of many factors, including duration and severity of stress, social support, and patient’s optimism, which contributes to ongoing autoimmune issues, but did not conclude that childhood trauma had any greater impact than stress reported in adulthood.

The medical field has clearly made the connection between epigenetics and the onset of autoimmunity. The field of psychology has shown that early childhood trauma and stress can contribute to health problems well into adult life. These studies have a tremendous impact on how we should treat patients with autoimmune disease, incorporating a more holistic approach to treating lupus, incorporating nutrition, meditation, and counseling alongside medication.

Childhood Trauma and Autoimmune Disease in Adults
It is estimated that 80% of patients diagnosed with autoimmune disease are women (Dube, Fairweather, Pearson, Felitti, Anda, & Croft, 2009), and in 2011, 51.1% of maltreated children were female (Children’s Bureau, 2012).  It is generally accepted that women are more often victims sexual abuse as both children and as adults and studies have shown that women are more likely to be diagnosed with autoimmune disease, especially lupus. Therefore it is vital that it be determined whether or not trauma increases the risk  of adult onset autoimmune disease.

Increased C-reactive protein (CRP) levels are an indicator of inflammation in the body, this inflammation is an indicated for many autoimmune disorders, including Rheumatoid Arthritis and SLE. Studies indicate that child abuse not only increases C-reactive protein (CRP) at the time of the abuse, but the increase continues being elevated up to 20 years after the abuse (Dube, et al., 2009). A review of the Adverse Childhood Experiences (ACE) study indicated that each increase in the amount of childhood trauma a person experienced, the more likely they would be hospitalized for autoimmune complications; “however, the relationship was statistically significant only for women” (Dube, et al., 2009) and each increased episode of trauma increased a woman’s likelihood of hospitalization by twenty percent.

Goodwin and Stein (2004) isolated specific illness and the impact that childhood physical abuse has on physical disorders in adults. They concluded that physical abuse significantly increased the likilhood of many health issues including autoimmune disease independent of issues with anxiety, depression and substance abuse. Further, looking specifically at gender, childhood abuse was more likely to indicate a predisposition for autoimmune disease in women, but not in men (Goodwin & Stein, 2004). Interestingly, once adjusted for instances of sexual abuse it was concluded that women had an increased likelihood of hospitalization only for cardiac related issues (Goodwin & Stein, 2004).

Both of these studies conclude that while they were able to show a potential relationship between childhood abuse and autoimmune disease, both indicate that other factors such as risky coping behavior or other environmental factors may also be culprits (Dube, et al., 2009; Goodwin & Stein, 2004).

Causality is impossible to prove when looking at things as complicated as early sexual trauma and autoimmune disease. With that said, current research strongly supports that a cross-discipline approach to treatment is absolutely necessary and should begin early in the treatment process. Treatment that includes medical care, psychological care and a strong support system may be the best way to insure that victims of childhood assault lead long healthy adult lives. 

Ballestar, E., Estellar, M., & Richardson, B. C. (2006). The Epigenetic Face of Systemic Lupus Erythematosus. The Journal of Immunology, 176, 7143–7147. Retrieved from http://www.jimmunol.org/content/176/12/7143
Children’s Bureau, U.S. Department of Health and Human Services, Administration for Children and Families. (2012). Child Maltreatment 2011. Retrieved from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment
Dube, S. R., Fairweather, D., Pearson, W. S., Felitti, V. J., Anda, R. F., & Croft, J. B. (2009). Cumulative Childhood Stress and Autoimmune Diseases in Adults. Psychosomatic Medicine, 71, 243–250.
Flett, R. A., Kazantzis, N., Long, N. L., MacDonald, C., & Millar, M. (2002). Traumatic Events and Physical Health in a New Zealand Community Sample. Journal of Traumatic Stress, 15(4), 303–312.
Goodwin, R. D., & Stein, M. B. (2004). Association between childhood trauma and physical disorders among adults in the United States. Psychological Medicine, (3), 509–520. doi:10.1017/s003329170300134x
Heim, C., & Nemeroff, C. B. (2001). The Role of Childhood Trauma in the Neurobiology of Mood and Anxiety Disorders: Preclinical and Clinical Studies. Biological Psychiatry, 49, 1023–1039.
National Institute of Health (NIH). (2008). Immune System: T Cells. Retrieved from http://www.niaid.nih.gov/topics/immunesystem/immunecells/pages/tcells.aspx
Putnam, F. W., & Trickett, P. K. (2006). Psychobiological Effects of Sexual Abuse:  a longitudinal study. Annals of the New York Academy of Sciences, 821(1). Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1997.tb48276.x/full
Sachs-Ericsson, N., Medley, A. N., Kendall-Tackett, K., & Taylor, J. (2011). Childhood Abuse and Current Health Problems Among Older Adults: The Mediating Role of Self-Efficacy. Psychology of Violence, 1(2), 106–120. doi:10.1037/a0023139
Stojanovich, L. (2010). Stress and autoimmunity. Autoimmunity Reviews, 9, A271–A276. doi:10.1016/j.autrev.2009.11.014
Stojanovich, L., & Marisavljevich, D. (2008). Stress as a trigger of autoimmune disease. Autoimmunity Reviews, 7, 209–213. doi:10.1016/j.autrev.2007.11.007
Sachs-Ericsson, N., Medley, A. N., Kendall-Tackett, K., & Taylor, J. (2011). Childhood Abuse and Current Health Problems Among Older Adults: The Mediating Role of Self-Efficacy. Psychology of Violence, 1(2), 106–120. doi:10.1037/a0023139
Zouali, M. (2011). Epigenetics in Lupus. Annals of the New York Academy of Sciences, 1217(1), 154–165. doi:10.111/j.1749-6632.2010.05831.x

Thursday, June 12, 2014

Anyone can be a father .... it takes someone special to be a dad!

I got a post on a blog the other day that mentioned Andy Rooney. It made me smile and think of my dad. We watched 60 Minutes together every Sunday and I always waited for Andy Rooney at the end, he was my favorite. 

I have a father, the man my mother was married to when I was born. He was my biological father. He died many years ago and he is actually a story for another time. With Father's Day this weekend this blog a tribute to my dad!

My mom re-married when I was four and my dad adopted me so that we would all have the same last name. He and my mother did not have other children .... I was it! My dad was not the easiest person in the world to live with. He had been in the military and believed there was only one way to do things "the right way." Growing up he was a meat & potatoes kind of guy and we would all have dinner together every night. We would watch "World News Tonight with Peter Jennings" on the little black&white TV in the kitchen with the orange flower 70s wallpaper. We could only speak during commercials so mom and I would try and fit in all we had to say while they were trying to sell some sort of cleaning product. I know is sounds pretty intense, but it wasn't. I learned a lot during those dinners. 

In fact, the most important and valuable life lessons I learned, I have learned from my dad.

I remember he taught me self defense in my room when I was little. He told me if I was ever in trouble I should shout "Fire" because no one will stop and help you unless they think they could be in danger as well.

He taught me how to laugh at British humor ..... Benny Hill, Monty Python ..... these were shows we watched together. I had no idea what I was laughing at, but my dad thought it was funny so I laughed too. I remember my mom would always get mad because it seemed like whenever she walked in the room Benny Hill was chasing a gaggle of bra clad women.

He taught me to love animals because unlike people they had no agenda. 

He told me I could be whatever I wanted and that I should never let anyone tell me otherwise. 

He told me I should never stop learning. We read magazines like Time and Newsweek, he always read nonfiction.

He taught me to dress respectably. He ironed his own clothes for work everyday and wore a jacket and tie. He did not wear jeans until he retired (this was the same time he bought a motorcycle).

He taught me to appreciate long rides along back roads, he taught me to climb rocks at Stage Fort Park in Gloucester .... while my mother looked on panic stricken. 

He hated dance recitals because they took all day, but he never missed a dress rehearsal ... where he had the option to come and go while waiting for my next routine (which taught me to multi-task so I could fit in the things that are important to me). He came to every play and every concert (though I am sure my mom had to elbow him a couple of times to keep him from snoring).

He taught me that the first time it is an accident .... the second time I need to take the blame (this applied to spilled milk, broken dishes or falls down the hill). 

He taught me that if I could get a "B" I could have worked harder and gotten an "A." He taught me I should read every day.

He taught me the importance of saving a dollar, wearing clothes until they are worn out. Everything you purchase has a life expectancy, take care of it as you would care for yourself. 

He taught me to swear properly and with feeling. This did not go well with the other neighborhood mothers as I tried to explain to people it was not puppy poop ..... it was dog shit.

He taught me that he would go to the ends of the earth for me as he saved me from a swarm of bees whose hive I had plunged through while climbing the rocks in the backyard.

My dad taught me the importance and value of a good nap! 

But the most important lesson my dad taught me is that you don't need to be blood to be family. It is a lesson I have brought with me into my relationships and friendships, a lesson I have tried to instill in my children. If you lead with your heart, the rest will fall into place. 

Today my dad passes these lessons on to my boys. He tries not to ever miss a soccer game, or a concert, or a birthday party. He may be a little older, a little slower, a little more cranky - but the lessons are still the same.

Happy Father's Day to all the fathers, dads, grandpas, uncles, step-dads, brothers and friends that help raise our children! Enjoy your day! 

I found some interesting Father's Day blogs & stories I want to share:
The Science of Being a Dad
White House Urges Dads to Join Work/Life Balance Conversation

Tuesday, June 10, 2014

Literature Tuesday .... my path

I have not written a Literature Tuesday post in quite some time. The reason for this is I have primarily been reading text books; big, thick, small print, dry, textbooks. While they impart vast amounts of knowledge, literature they are not! 

Although Millon here came closest in his extensive history of personality disorders and the evolution-based personality theory he has developed to explain the Axis II disorders and their treatments. 

As I reviewed my last post so I could remember exactly what I wrote about (memory issues and lupus - probably my least favorite symptoms) I thought about the path my life has taken, which in turn reminded me of my favorite poem - the one I always use as my quote if I am asked for one. I went to Plymouth State College for a couple of years and was very excited to discover that Robert Frost had taught there and that I was taking my English classes in a building in which he lived. I was inspired (someday I may share some of the work I wrote while there - when I get over the embarrassment of what I wrote and am able to laugh at myself a little).  There were many of Frost's poems I fell in love with at the time: Mending Wall, A Brook in the City, Gathering Leaves, and One Step Backward Taken. But always, from the first moment my eyes fell upon the words I connected with the Road Not Taken. And while I can say without a doubt that the road not taken has led me on an interesting and wild journey, I have often wondered about the path I did not take, the one we never get to go back to. Then I shake my head and smile because if I had made a different choice, if I had followed the more worn path I wouldn't be who I am today, and I certainly would not want that. 
Frost House @ Plymouth State University
Where I took my English Classes!

The Road Not Taken
Robert Frost
Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,
And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I-
I took the one less traveled by,
And that has made all the difference.

Robert Frost Statue @ Plymouth State University

Thursday, June 5, 2014

Thoughtful Throwback Thursday ......Ahhhh to be young again

So once again it is Throw-back Thursday. But for me it was nightmare midterm day. Two exams that I studied really hard for. One I did well on .... the other not so much. Shear panic hit the moment he put the paper in front of me. And I looked around at all the young adults who were breezing through their exams and I panicked a little more - and that was it, I was all done.

Jung, Beck, Freud, Millon, Buss, antisocial, borderline, CAPS Theory, Attachment Theory, psychodynamics, defense mechanisms, Evolutionary Theory ........ blah, blah, blah .... it all became one jumble of information in my brain that I just could not sort through ... so I guessed. The good news is the exam was multiple choice and so I had a 25% chance of getting each one correct. Glass half full right!

After I stopped crying on the ride home I wondered what it would be like if I had done things differently and figured out what I wanted to be when I grew up when I was in my twenties instead of when I was in my forties. Where would I be now?

I came of age in the 1980s - my role models were Madonna and Pat Benatar. I went to the movies and wanted desperately to be Andy from Pretty in Pink while at the same time I identified with Allison in the Breakfast Club. I listened to both Heart & Zepplin and watched The Wall looking for the meaning of life; but deep down I was a Goonie 'till the end! I learned feminism from Salt N' Pepa and formed my rebellion watching the Legend of Billy Jean & Footloose when we finally got cable. My vampires did not sparkle, and that was ok because they introduced me to the Doors. Rod Stewart led me to believe I could make it on my own.

But in all those contradictory identities I tried on as I came of age I never really knew what I wanted to be. I never thought about careers or college or the future (unless it had a DeLorean involved). The 1980s were the "me" generation. We believed we could be anything we wanted to be ... the problem was there were a lot of us that had no idea what that meant.

When I finally ended my rebellion against the "man" and tried to figure out what I was going to be, my ideas were still pretty grandiose. I was by this point in my early twenties and I wanted to be a journalist - the next Woodward or Bernstein or Cronkite or Jennings. I was going to save the world with my insight as a crusader for the downtrodden. My undergraduate degree is in journalism; I worked for a summer at a small local newspaper and realized that the reality of "writing" for a paper consisted of obituaries, and craft fairs and spending the day in court writing about who got arrested - all valid and useful information - but I realized I was not going to topple corrupt governments where I was. So I got a degree in domestic violence advocacy - at least here I thought I would do some good, and I think I did. I worked in a shelter for a few years as an advocate, but the pay was awful (I was a single mother trying to survive) and the hours were miserable and the stress was intense almost everyday. I burnt out quickly and went back to what I was good at - higher education and pushing paper! The pay is ok, the hours are usually flexible, and sometimes I even still have an impact.

But the calling to move on is strong, the question of what do I want to be when I grow up ever present. What legacy am I going to leave to my children? And so here I am, in my forties sitting with kids in their twenties, trying to make it all work, fitting an internship into my already chaotic life, sitting on my hands when I want to tell the professors none of this really matters in the real world - teach me skills, not theory. 

I started this blog during my midterms in April- and just got around to finishing it more than a month later. That is where my life is at right now. And that is ok. If you don't keep learning, I believe your brain dies. I don't mean everyone needs to go back to graduate school in their forties (in fact I am not sure I would recommend that to anyone), but you need to keep learning, you need to keep changing, you need to be willing to "take chances, make mistakes & get messy" (sorry - I have been watching a lot of Magic School Bus with the 7-year-old). It is, however, a valuable lesson and that is the legacy I want to leave my children.

So what would have happened if I went the traditional route - perhaps I would have my Ph.D. and a private practice - but I am not sure I would have been happy. Happiness should not be found in the destination, it should be found in the journey!