The Earthquake Assessment ©(Sichel & Driscoll, 1999)

Jeanne Watson Driscoll, PhD, APRN, BCOctober 5, 2007

Women’s Health: Addiction, Trauma & HOPEPrinceton, New Jersey

Objectives 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 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 Corpus Callosum: 23% larger

(Gorsky & Allen) Language area 30% larger (Harasty)

Paralimbic Cortex more active (Gur & Gur)

Facial recognition easier (Gur & Gur)

Allostasis The history

Cannon: homeostasis Role of feedback mechanism to reduce

variability and maintain constancy Failed regulation-antecedent to illness

General Systems theory Dynamic non-linear process

Seyle (1956) General adaptation syndrome Proposed that chronic stress may

have an accumulative damaging effect on physiology

McEwen Allostasis and allostatic loading

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 Perceptions or actual experiences

of environmental demands (either internal or external) that tax or exceed and individual’s ability to cope ( Lazarus & Folkman, 1984).

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) A concept that describes the

relationship between psychoneurohormonal responses to stress and physical and psychological manifestations of health and illness

Allostasis (Bruce McEwen)

Allostasis is the process of achieving stability through change 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

There are significant links between molecular physiological systems, structures and functions of the brain, emotional interpretation and coping capabilities

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 Hippocampus-pituitary-adrenal

axis (HPA) Autonomic Nervous System (ANS) Immune system (inflammatory

cytokines) Adrenal Cortex (glucocorticoids) Adrenal Medulla (adrenalin)

“Brain Strain” (Sichel & Driscoll, 1999)

Allostatic Loading (McEwen) 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 Frequent stress Adaptation to

repeated stressors of the same type, resulting in the prolonged exposure of the body to the stress hormones

Inability to shut allostatic responses after the stress is terminated

Inadequate responses from some allostatic systems trigger compensation in others

Implications for human society 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 Does not feel pain Distress is interpreted through

signs and symptoms Mood, anxiety, and physical

symptoms are demonstrated

Braingenetics

Stress Hormones

ReproductiveHormones

Neurotransmitters

Symptoms:Psychological

Physical

Key vulnerable times in a woman’s life

Menarche Premenstrual Pregnancy Infertility Postpartum Perimenopause Menopause

The Earthquake Assessment(Sichel & Driscoll, 1999)

Metaphor to describe “allostatic loading” and the impact on brain biology

Definitions Fault lines: biochemical brain Tremors: sub-clinical symptoms Earthquake: major psychiatric episode

Assessment areas: genetics; life events; and reproductive events

Critical Assessment Domains Genetic/family history Live events/Life stressors and

reactions Reproductive events and reactions

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 Process

Assessment Questions Genetic History

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?

Did you Mother experience any mood/anxiety problems around reproductive events?

Any one been on any psychiatric medications? (give names)

Life Events/Stressors Chronological Ages

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 Onset of first period?

Any hx. of mood/anxiety prior Any hx. of migraine h/a, stomach

aches, physiological disturbances? Oral/depot contraceptive history Pregnancy history

Number of pregnancies

Any abortions/miscarriages If positive pregnancy history:

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

Menstrual history 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 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 Nourishment and Needs Understanding Rest and Relaxation Spirituality Exercise

Nourishment and Needs 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 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 Sleep: key assessment area Sleep rituals: Develop a sleep

hygiene program Power naps Meditation, visualization,

mindfulness Yoga, stress reduction strategies

Spirituality 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 Find an exercise that you enjoy and do

it! 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 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.

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.

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.

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.