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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.