Author Topic: Medical links between abuse and health  (Read 1344 times)

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Offline AuntieEm2

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Medical links between abuse and health
« on: February 04, 2011, 03:57:36 PM »
Events of violence and abuse in one's past (or present) are linked to health consequences that can endure for a lifetime. An emergency medicine physician at The Academy on Violence and Abuse (http://http://www.avahealth.org) has documented the effects of violence and abuse on nearly every system of the body: cardiovascular health, allergies, neurological, OB-GYN, mental health, chronic pain and more. The AVA finds that medical practitioners rarely investigate whether a patient's, oh, say, heart disease might have its origins in the stress effects of abuse in the patient's past--nor do practioners tend to know how to treat it. This is an emerging field in medical practice, and more research is needed.

My purpose in posting this is so that survivors may be informed that present-day health problems may result from past abuse and violence.  

See a (complicated) diagram of health effects here:
http://http://www.avahealth.org/vertical/Sites/%7B75FA0828-D713-4580-A29D-257F315BB94F%7D/uploads/%7B6B9D42D0-4DC8-46E2-AF5D-8E556D1BD12C%7D.PDF

Important study call the Adverse Childhood Experiences Study (ACES) that proved the link between adverse experiences in childhood, and health and behavioral outcomes later in life:
http://http://www.acestudy.org/

Feel free to PM me with questions, if you prefer.

Auntie Em
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Offline Ursus

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Re: Medical links between abuse and health
« Reply #1 on: February 04, 2011, 04:10:14 PM »
Quote from: "AuntieEm2"
Important study call the Adverse Childhood Experiences Study (ACES) that proved the link between adverse experiences in childhood, and health and behavioral outcomes later in life:
http://www.acestudy.org/
Some earlier coverage of the ACE study:

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Offline Truckin'

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Re: Medical links between abuse and health
« Reply #2 on: February 06, 2011, 09:53:59 PM »
One other thing not exactly mentioned here is the effect of early trauma and neglect on the formation of a child's brain. There is a lot written about this.
There's evidence that some of this is reversible, though.

Check these out:  http://www.youtube.com/watch?v=65HGGA0b ... re=related and http://www.youtube.com/watch?v=AsCViRHzGHE&NR=1
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Offline seamus

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Re: Medical links between abuse and health
« Reply #3 on: February 07, 2011, 02:33:54 AM »
I do not expect to be sixty. :nods:
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Offline Truckin'

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Re: Medical links between abuse and health
« Reply #4 on: February 07, 2011, 12:13:51 PM »
Quote from: "seamus"
I do not expect to be sixty. :nods:
I'm guessing not, if your public persona is anything like your online persona! ;)
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Offline seamus

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Re: Medical links between abuse and health
« Reply #5 on: February 10, 2011, 06:05:24 AM »
hey, you live thru,adecade of herion addiction,straight,and acouple of stints, locked up,throw 10+ years of ambulance / coroners office duty on top and think what? sockpuppet.




I wont get into my childhood,either.
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Offline Truckin'

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Re: Medical links between abuse and health
« Reply #6 on: February 10, 2011, 11:18:01 PM »
Quote from: "seamus"
hey, you live thru,adecade of herion addiction,straight,and acouple of stints, locked up,throw 10+ years of ambulance / coroners office duty on top and think what? sockpuppet.

I wont get into my childhood,either.

Well, sockpuppet (?) I guess that excuses your nasty attitude, eh?
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Offline Ursus

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The Hidden Toll of Abuse
« Reply #7 on: February 11, 2011, 01:13:29 AM »
Quote from: "AuntieEm2"
Events of violence and abuse in one's past (or present) are linked to health consequences that can endure for a lifetime. An emergency medicine physician at The Academy on Violence and Abuse (http://www.avahealth.org) has documented the effects of violence and abuse on nearly every system of the body: cardiovascular health, allergies, neurological, OB-GYN, mental health, chronic pain and more. The AVA finds that medical practitioners rarely investigate whether a patient's, oh, say, heart disease might have its origins in the stress effects of abuse in the patient's past--nor do practioners tend to know how to treat it. This is an emerging field in medical practice, and more research is needed.
Here's a related article from Minnesota Medicine, focusing on that very physician and the work of the Academy on Violence and Abuse:

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Minnesota MEDICINE
August 2009 · Cover Story

The Hidden Toll of Abuse
David McCollum, M.D., wants health care professionals to know that abuse and neglect are often the underlying cause of chronic illness.

By Howard Bell


David McCollum, M.D. Photo by Steve Wewerka

David McCollum, M.D., first saw the not-so-hidden costs of domestic abuse while a resident in San Bernardino, California, where he watched police fatally shoot a man who held his estranged and battered wife at gunpoint in the emergency department parking lot. He began to see the hidden costs in 1980, when he opened a solo family practice in Chanhassen. His practice was slow to take off (he saw only one patient his first day), which gave him a diagnostic tool most physicians wish they had more of—time, so he encouraged patients to tell him about themselves. "I heard lots of stories about bad things happening to them. A surprising number were victims of abuse or neglect, at home or at work, now or in the past," says McCollum, who is now 61 and an emergency physician at Ridgeview Medical Center in Waconia.

McCollum began to notice what research has since confirmed: People who have been abused or neglected at some time in their lives go to the doctor more than other people. They have maladies ranging from fibromyalgia and irritable bowel syndrome to common and costly conditions such as cardiovascular disease, diabetes, and hypertension. They make more visits to ERs, hospitals, and mental health services, too. And they have more surgeries, and those surgeries are less likely to succeed.

Keen Observer
McCollum continued to see the same connection between abuse and chronic illness at Ridgeview, where he has been on the staff for 29 years. With no formal knowledge or training in abuse and neglect, McCollum learned to read the sound of his patients' voices and the look on their faces. "I got to where I could tell within a couple minutes what was going on with them," he says.

By the early 1990s, he began to participate in online physician discussions and queried colleagues in the hallway about abuse and neglect. One colleague told him 100 percent of his chronic headache patients had a history of child sexual abuse. Another told him 70 percent of his fibromyalgia patients had that history. "It became clear to me that their abusive experiences harmed their health in ways that went far beyond the obvious physical and mental trauma abuse causes."

McCollum also noticed that the type of abuse or neglect didn't seem to matter. Child abuse, intimate partner violence that is physical or verbal, elder abuse, sexual abuse, so-called "white collar abuse" at the office, or post-traumatic stress disorder (PTSD) from military experience—all in similar ways cause or worsen a number of pathologies not obviously or directly connected to the abuse or neglect.

He made one more observation—perhaps the most important one. "Simply acknowledging to patients that the abuse they experienced is hurting their health can greatly improve their health," he says.

But most physicians don't broach the topic with patients, according to McCollum. Nor do they acknowledge or act upon the growing stack of studies that show abuse and neglect predispose people to chronic illness. Instead, many physicians prefer to treat the specific complaint the patient came in for and view abuse and neglect as a criminal justice or social service issue. "It bothered me that so much abuse goes on in our society with so much hidden effect on a person's health, yet we doctors weren't doing anything about it."

So McCollum decided he'd do something.

While serving on the American Medical Association's National Advisory Council on Violence and Abuse, he met Marie Christensen, M.D., a plastic surgeon at Park Nicollet Clinic. Christensen was noticing the same pattern in her patients. "Something hidden affected their ability to enjoy their outcomes and made patients less cooperative with postoperative care instructions," she says. Some were chronic overeaters or had unexplained pain or GI symptoms. And a surprising number of those patients had experienced sexual or child abuse, abuse in the workplace, or domestic abuse.

In 2005, Christensen and McCollum co-founded the Academy on Violence and Abuse (AVA), along with 18 other health care professionals and advocates, some of whom had served on the AMA's advisory council or were involved in the San Francisco-based Physicians for a Violence-Free Society. (McCollum, who served as AVA president for two years, is now chairman of its board.) The charter members were inspired by what they saw in their exam rooms and by the 2002 Institute of Medicine report "Confronting Chronic Neglect: the Education and Training of Health Care Professionals on Family Violence," which concluded that physicians were not adequately trained to recognize abuse and neglect in their patients and were not aware of how past experiences of abuse and neglect could cause or worsen common chronic illnesses. Their goal was to address this need so that physicians and all other health care professionals could identify abuse or neglect, discuss with the patient how these experiences can affect their health, and arrange for appropriate support services as needed.

Based in Eden Prairie with a membership that today includes more than 100 members including physicians and other health care professionals from throughout the United States, the AVA is working to make this happen by informing practitioners about research on the biochemical and physiological changes brought on by abuse and neglect; giving physicians tools to identify abused or neglected patients and to determine if past or present abuse may be contributing to those patients' health problems; and working with academic health centers to integrate information on abuse and neglect into medical and other health-related curriculums.

Abuse and Illness
When McCollum, Christensen, and other AVA members speak to physician groups, they use an illustration that looks sort of like a sea monster with tentacles extending in all directions to show how abuse and neglect affect nearly every organ and system. Some are known consequences that have been solidly researched; others are suspected based on substantial anecdotal evidence.

Recent research, for example, shows how abuse and neglect change neuron patterns in the brain, especially if the events occur in childhood. Victims of abuse and neglect at any age have higher levels of a neuropeptide called substance P that mediates pain response. The more substance P a person has, the more sensitive he or she is to pain. Levels can be four times higher in people who experienced abuse or neglect in early childhood, according to McCollum. "People do feel pain differently," he says. Researchers also have found elevated levels of substance P in the intestines of people with irritable bowel syndrome, which childhood victims of abuse and neglect have at a much higher rate than people who have not experienced abuse.

Evidence suggests exposure to abuse and neglect induces in some a state of chronic pain that makes them more vulnerable to stress-related illnesses. It's theorized that the resulting chronic pain is caused by biochemical disruption of the hypothalamic-pituitary-adrenal axis, causing both endocrine and neurological consequences.
 
Abuse and neglect also produce chronic stress, which can lead to elevated levels of cortisol, inflammatory cytokines, and other responses that change how neurons grow and connect in childhood and how the brain and organ systems function in adults. For example, victims of childhood abuse and neglect continue to have higher cortisol levels as adults and their corpus callosum, which connects the brain's hemispheres, is often significantly smaller, according to McCollum. He adds that this is one of many structural changes that take place in the brain.

In addition, elevated stress hormones affect the nervous, endocrine, and immune systems, which in turn adversely affect other organs and systems. This helps explain why victims of abuse and neglect have higher rates of so many different conditions. For example, victims of childhood abuse and neglect are 1.3 to 1.7 times more likely to have coronary artery disease as adults, according to a benchmark 1998 study by Felitti et al. published in the American Journal of Preventive Medicine. Analyzing the long-term health of 17,000 people of all ages, ethnic groups, educational levels, and socioeconomic classes, the researchers also found that victims of adverse childhood experiences also had a higher incidence of addictions, sexually transmitted diseases, obesity, fractures, diabetes, COPD, rheumatoid arthritis, lung cancer, and thyroid disorders.

In addition to experiencing these physiological effects, people who experienced abuse and neglect are more likely to smoke, overeat, abuse drugs and alcohol, engage in reckless behaviors that cause accidents, and be sexually promiscuous, according to the Felitti study.

In Every Doctor's Office
With 20 to 40 percent of the U.S. population having a history of abuse or neglect significant enough to cause health consequences, the costs to society are high.

Between 17 percent and 37 percent of dollars spent on health care in this country are spent treating direct and indirect consequences of abuse and neglect, according to the AVA. Victims of significant abuse and neglect use the health care system two- to two-and-half times more often than the rest of the population, according to a 1992 study in the Archives of Family Medicine. A 1999 study by Wisner published in the Journal of Family Practice showed that a large Minnesota health insurance plan spent $1,176 more per year on female enrollees who had a history of violence and abuse than other female enrollees. In another study published in the American Journal of Preventive Medicine in 2007, women with such a history had up to 20 percent higher health care costs, and those costs continued long after the abuse and neglect ended. "Abuse and neglect are in every doctor’s office, and it's a medical issue we must address in the exam room," says Stuart Hanson, M.D., a Park Nicollet pulmonologist who joined the AVA because he saw it as the best way to create awareness about an issue he's been concerned about since the 1980s. While he was the Minnesota Medical Association's president in 1993, Hanson led a broad initiative to stop verbal and physical abuse. He personally emphasized the importance of creating awareness of abusive behaviors in the medical workplace. "I thought physicians had better practice what we preach," he says.

But physicians are reluctant to do this. Most are uncomfortable with the topic, because they don't want to offend the patient. And many don't know how to elicit an abuse history. Asking about abuse can be time-consuming. And if they do uncover a history of abuse, what then? "It's as hard for the doctor to talk about as it is for the patient, especially when most of the time the patient is being seen for reasons not directly related to abuse and neglect," says Laura Meis, Ph.D., a post-doctoral fellow in psychology who researches relationship distress, abuse, and PTSD at the Minneapolis Veterans Affairs Medical Center.

Physicians also don't want to ask about a problem they may not have a solution for, according to Therese Zink, M.D., M.P.H., a professor of family medicine at the University of Minnesota who researches what abused patients want from their doctor. "Realize that you may not be able to fix it," she says, "but you can be there to support your patient and refer them to professionals who can help when they are ready to take that step."

Zink says physicians can do five things for patients: They can screen for a history of abuse and neglect; discuss with patients the effects abuse can have on their health; acknowledge the patient's feelings and affirm that the abuse is real; refer patients to professionals who can provide therapeutic interventions; and document the abuse in the medical record. (To learn how other physicians do this, see "Tips from Colleagues")

If the abuse or neglect involves a child or vulnerable adult, providers are mandated by law to notify the authorities. In other cases, law enforcement should only be called if a patient's wounds were inflicted by a gun, knife, fire, chemical, or other dangerous weapon or if an adult victim wishes to report the incident, according to McCollum.
 
However, most abuse, including verbal and emotional abuse, is not a crime. In such cases, McCollum says, it's more important to focus on the patient's needs. That may include making sure the person is safe and offering referrals to counselors or therapists who specialize in the consequences of child sexual abuse, PTSD, or domestic or family violence.

Changing the System
Getting physicians and clinics to routinely and thoroughly deal with abuse and neglect will mean changing how medical students and residents are trained and retraining practicing physicians.

"What students need to learn," says Hanson, "is the basic science of how the brain and body respond to abuse and neglect—the brain changes and physiological changes they cause." Christensen adds that physicians-in-training must be taught to automatically ask themselves, "How could abuse or neglect be present in this particular pathology I'm looking at?"

At the AVA's annual conference last spring, medical school researchers, faculty, and administrators talked about creating such a curriculum. And in October at the Family Violence Prevention Fund Conference, the AVA again will host a discussion about what competencies medical students, residents, and other health professionals should have after completing training. But McCollum believes curriculum changes must come from within academic medicine. "It's hard for academic institutions to respond to people coming at them from outside," he says. "We need physician champions in the upper echelons of academic medicine who can encourage junior faculty to take this on." McCollum would like to see an academic medical center in Minnesota include content on the medical aspects of abuse and neglect and its public health consequences in its curriculum. "I'm not aware of any Minnesota medical center interested in doing this," he says. "But we are confident that will change."

Some AVA members would like to see abuse and neglect medicine become its own subspecialty, complete with fellowships, board exams, and credentialing. (It's already possible to complete a pediatric fellowship in abuse and neglect.)

But retrofitting medical training programs will take decades, according to Hanson. "We're five years into a 20-year process." For that reason, he feels it's just as important to educate practicing physicians. To some degree, that's already happening. Arne Graff, M.D., a child abuse expert and family physician who also serves as medical director for Child and Adolescent Maltreatment Services at MeritCare Health System in Fargo, presents CME on the subject in North Dakota and northwestern Minnesota. Yet he, McCollum, and Christensen express the same frustration. "It's hard to get physicians to come to training that’s not obviously related to what they do," Graff says.

Teaching doctors how to talk to patients about abuse and neglect does work, according to Anita Berg, director of the St. Paul-based Partners for Violence Prevention. Since 1996, Partners has had 2,200 Minnesota physicians complete its Domestic Violence 101 class, recently renamed Relationship Health, Violence Prevention, and Health Promotion. After training United Hospital personnel from the emergency department, birthing center, and behavioral health service, victim identification jumped from two to three patients per quarter to 50 to 75 per quarter; then it jumped again to 100 per quarter after United made the class part of new-employee orientation.

Many may think it ludicrous to expect harried doctors to delve into delicate, complex issues during a typical office visit. AVA members admit it's a challenge but argue that taking the time to do so can save much more time later. "When I reviewed one patient's record and found she'd come to the emergency department 52 times in two years, I identified and addressed the abuse underlying her complaints," McCollum says. "After that, she came in only five times the next year. The time savings down the road is incredible."

McCollum and oth ers with the AVA hope that those who pay for health care will one day encourage physicians to inquire about abuse and neglect. "Payers already know how costly it is to treat chronic illness," he says. "They can significantly lower those costs and reduce utilization by placing this expectation on clinics."

As a last resort when he is trying to convince skeptical physicians and nurses to look for underlying abuse and neglect, Graff says he reminds them that they have a legal responsibility to document and report abuse of children and vulnerable adults. But physicians are not legally responsible to uncover past abuse and neglect that may be affecting a patient’s current health in hidden ways. Here, McCollum says physicians have a professional responsibility. "Our job is to find the source of a patient's maladies," he says. "Any technician can dispense pills. But it's amazing what you can do for the patient by just uncovering the hidden reasons they feel the way they feel." MM

 
    For More Information The Academy on Violence and Abuse website,
www.avahealth.org, includes links to articles about diseases and clinical presentations related to abuse and neglect, including its own white paper "Hidden Costs in Health Care: The Economic Impact of Violence and Abuse," which summarizes research on the long-term hidden health and economic consequences of abuse and neglect.[/list][/size]
Howard Bell is a medical writer in Onalaska, Wisconsin.
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Offline AuntieEm2

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Re: Medical links between abuse and health
« Reply #8 on: February 11, 2011, 03:10:13 PM »
Thank you, friendly bear-man.

I really hope this can help some people.

Auntie Em
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Offline Ursus

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Re: Medical links between abuse and health
« Reply #9 on: February 12, 2011, 10:54:45 PM »
Quote from: "AuntieEm2"
Thank you, friendly bear-man.

I really hope this can help some people.

Auntie Em
Naaahhh... Thank YOU, Auntie Em, for posting 'bout this important issue!   :hug:

I also hope it can help validate what some people having been suffering through.
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Offline Ursus

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Re: The Hidden Toll of Abuse
« Reply #10 on: February 12, 2011, 10:59:54 PM »
From the above article by Howard Bell, "The Hidden Toll of Abuse":

    But retrofitting medical training programs will take decades, according to Hanson. "We're five years into a 20-year process." For that reason, he feels it's just as important to educate practicing physicians. To some degree, that's already happening. Arne Graff, M.D., a child abuse expert and family physician who also serves as medical director for Child and Adolescent Maltreatment Services at MeritCare Health System in Fargo, presents CME on the subject in North Dakota and northwestern Minnesota. Yet he, McCollum, and Christensen express the same frustration. "It's hard to get physicians to come to training that’s not obviously related to what they do," Graff says.[/list][/size]
    One of the biggest roadblocks I see here, despite the focus and hopeful tenor of the article, is not so much the physicians themselves, but the cultural climate of our HMO dominated health care system, which simply does not avail the time for such individual attention despite it's being quite warranted.
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    Offline seamus

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    Re: Medical links between abuse and health
    « Reply #11 on: February 13, 2011, 06:50:36 AM »
    Quote from: "Truckin'"
    Quote from: "seamus"
    hey, you live thru,adecade of herion addiction,straight,and acouple of stints, locked up,throw 10+ years of ambulance / coroners office duty on top and think what? sockpuppet.

    I wont get into my childhood,either.

    Well, sockpuppet (?) I guess that excuses your nasty attitude, eh?
    no excueses, dont offer any, just a real basic dislike for painted lies and dis infomation.
    « Last Edit: December 31, 1969, 07:00:00 PM by Guest »
    It\'d be sad if it wernt so funny,It\'d be funny if it wernt so sad

    Offline AuntieEm2

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    Re: Medical links between abuse and health
    « Reply #12 on: February 14, 2011, 11:25:38 AM »
    Quote from: "Ursus"
    From the above article by Howard Bell, "The Hidden Toll of Abuse":

      But retrofitting medical training programs will take decades, according to Hanson. --snip-- Yet he, McCollum, and Christensen express the same frustration. "It's hard to get physicians to come to training that’s not obviously related to what they do," Graff says.[/list][/size]
      One of the biggest roadblocks I see here, despite the focus and hopeful tenor of the article, is not so much the physicians themselves, but the cultural climate of our HMO dominated health care system, which simply does not avail the time for such individual attention despite it's being quite warranted.

      Though the article also says:

        For example, victims of childhood abuse and neglect are 1.3 to 1.7 times more likely to have coronary artery disease as adults, --snip-- of 17,000 people of all ages, ethnic groups, educational levels, and socioeconomic classes, the researchers also found that victims of adverse childhood experiences also had a higher incidence of addictions, sexually transmitted diseases, obesity, fractures, diabetes, COPD, rheumatoid arthritis, lung cancer, and thyroid disorders.[/list]
        Which suggests that to reduce costs, insurers may embrace broader efforts to prevent and treat abuse. If they won't do it out of compassion, perhaps they'll do it out of greed...

        I also think patients need to start asking for a higher standard of care in this arena. A checkbox on a health history form doesn't cut it anymore.
        « Last Edit: December 31, 1969, 07:00:00 PM by Guest »
        Tough love is a hate group.
        "I have sworn...eternal hostility against every form of tyranny over the mind of man." -Thomas Jefferson.