Transcript Post-traumatic Stress Disorder and Substance Use Disorders

Post-traumatic Stress Disorder
in Addictions
Elisa Triffleman, MD
The Public Health Institute,
Berkeley, CA
Yale University School of
Medicine, New Haven, CT
Outline of Presentation:
I. Diagnosis and Screening
II. Epidemiology and Comorbidity
III. Neurobiology and Treatment
Approaches
Outline of Presentation:
I. Diagnosis and Screening
II. Epidemiology and Comorbidity
III. Treatment Approaches
The DSM-IV Definition
of Trauma:
“Criterion A.: The person has been
exposed to a[n]…event in which both of
the following were present:
“1. The person experienced, witnessed,
or was confronted with an event or events
that involved actual or threatened death
or serious injury, or a threat to the
physical integrity of self or others….
DSM-IV Trauma:
“2. The person’s response involved
intense fear, helplessness or
horror…”
from: American Psychiatric Association,
Diagnostic and Statistical Manual, 4th
Edition--Text Revision, 2000.
DSM-IV Post-traumatic Stress
Disorder (PTSD)
At least 1 re-experiencing symptom:
“Classic” PTSD Symptoms
Nightmares (or evidence thereof)
Flashbacks
Intrusive memories
Physiological reactivity with reminders
Cue-related distress
DSM-IV Post-traumatic Stress
Disorder (PTSD)
At least 3 symptoms of avoidance,
numbing and estrangement:
Avoidance of internal or external cues
Emotional estrangement
Emotional numbing
DSM-IV Post-traumatic Stress
Disorder (PTSD)
Avoidance symptoms, cont’d:
Decreased interest in pleasurable or
usual activities
Psychogenic amnesia
Sense of a foreshortened future
DSM-IV Post-traumatic Stress
Disorder (PTSD)
At least 2 symptoms of hyperarousal;
Sleep disturbances
Hyperstartle
Irritability or anger outbursts
Hypervigilance
Decreased concentration
DSM-IV Post-traumatic Stress
Disorder (PTSD)
Duration and Impairment Criteria:
Occurring > 1 month post-trauma
Lasting > 1 month
Interfering with function
Subsyndromal PTSD
Also known as “partial PTSD”
No single, agreed-upon definition, but
most commonly:
 2 out of 3 symptom cluster criteria,
or
 1 intrusive-cluster symptom and
meeting full criteria for another symptom
cluster
 Stein et al (1997) Am J Psychiatry, 154(8):1114-1119
Diagnostic Instruments
Interviews:
Clinician Administered PTSD Scale
Structured Clinical Interview for DSM-IV
(SCID) PTSD module
Structured Interview for PTSD
Diagnostic Instruments
Self-administered questionnaires:
Posttraumatic Diagnosis Scale
Coffey et al (1998): validation among detox
patients
Impact of Event Scale-Revised
Davidson Traumatic Stress Scale
PTSD Checklist
Outline of Presentation:
I. Terminology
II. Epidemiology and Comorbidity
III. Neurobiology and Treatment
Approaches
National Comorbidity Survey
PTSD prevalence: 5% males,10% female
Among those with PTSD:
Alcohol use disorders prevalence:
51.9% (OR=2.06) among males;
27.9% among females (OR=2.48)
Drug use disorders (excl nicotine):
34.5% (OR=2.97) among males, 26.9%
(OR=4.46) among females
Kessler et al. (1995) Arch Gen Psychiatry 52:1048-1060
Rates of PTSD-Substance Use
Disorders in Specific Samples
14% among community Gulf war
veterans
20% among mixed-gender substance
abuse outpatients (Triffleman, et al 1995)
Typically cited rates:30-50%
59% among community women in the
South Bronx (Fullilove, 1993)
Rates of PTSD, Cigarette Use
Beckham et al (1997): N=445 male VN
Vets:
Combat vets with PTSD smoked more
cigarettes than combat vets without PTSD
48% of PTSD+ vets vs 28% of PTSDvets smoked >25 cigs per day
Medical problems and PTSD
Higher rate of medical problems,
including:
HTN
Chronic pain disorders
Heart disease
GI disorders
Medical problems and PTSD
Higher rate of HIV risk behaviors
Kimmerling, et al (1998): Higher than
expected rates of PTSD among HIV+
women
Higher rate of mortality
Disorders co-occuring with
PTSD and addiction
 Major depression and dysthymia
 Anxiety disorders (panic disorder,
social phobia)
 Psychotic disorders
 Borderline, antisocial personality disorders
 Dissociative disorders
Outline of Presentation:
I. Diagnosis and Screening
II. Epidemiology and Comorbidity
III. Neurobiology and Treatment
Approaches
Neurobiology of PTSD
Increased catecholamines, decreased
alpha-2 adrenergic receptors
HPA disturbances: decreased
glutocorticoid levels, increased
glutocorticoid receptors
Increased central corticotropin-releasing
factor
Neurobiology of PTSD
Serotonergic dysfunction
Reduced beta-endorphin levels and
increased pain thresholds
Brain Activation Changes in
PTSD
Hendler et al (2003) NeuroImage, 19: 587-600
Psychopharmacological
Approaches to PTSD
Psychopharmacotherapy for the
Dually Diagnosed
Treating the nonsubstance Axis I
disorder:
The nonsubstance Axis I disorder improves
The substance use disorder may improve, but
does not go into remission
Treatment retention improves
May have a durable effect, even after
discontinuation
Psychopharmacotherapy for the
Dually Diagnosed
Treating the Substance Use Disorder:
Any medication useful for the treatment of
addiction is useful in the treatment of dually
diagnosed individuals
But that does not mean there is a specific
psychotropic effect beyond anti-addiction
mechanism and decrease in substanceinduced psychiatric symptoms
Psychopharmacological
Approaches
In PTSD, medications are part of an
integrative strategy
As with psychotherapy, everything has
been tried
Psychopharmacological
Approaches
Antidepressants
RCT’s done in PTSD on:
SSRI’s (Fluoxetine, Paroxetine, Sertraline)
SSNRI (Mirtazapine)
TCA (Amitryptyline, Imipramine)
MAOI (Phenelzine, brofaromine)
Psychopharmacological
Approaches
Mood-stabilizing anticonvulsants (antiglutaminergic):
RCT on lamotrigine
Atypical antipsychotics
RCT’s on risperidone, quetiapine
Psychopharmacological
Approaches
Anti-adrenergic agents
RCT on Prazosin
Clonidine used frequently in children
Psychopharmacological
Approaches
Benzodiazepines:
1 RCT: Alprazolam vs placebo, 3.75
mg qD: no effect on core PTSD
symptoms
Benzodiazepines in PTSD
depends on the setting, the disorder and
the patient
Appropriate for use in intensive settings for
treatment of acute exascerbations of PTSD and
for detoxification—but still must make a clear
decision regarding continuation prior to
discharge
Should be used with caution in other settings
and for other purposes
Pharmacotherapy for PTSD-SUDs:
A case series regarding sertraline
(Zoloft):
N=9 civilian male and female subjects
Current alcohol dependence+PTSD
The severity of both PTSD and alcohol
dependence symptoms declined
significantly over the course of the 12week trial in 6 treatment-completers.
 Brady et al (1995) J Clin Psychiatry 56:502-505
Psychosocial Treatment
Research Trials
in PTSD: without SUDs?
Many of the trials have included those with
concurrent PTSD-SUDs
Marks et al (1998): 17% of subjects were
alcohol dependent
Resick (2002): excluded subjects with substance
dependence, advised substance abusing
subjects not to use while in treatment
Outcomes for those with SUDS unknown
Impact of Concurrent
Treatment of PTSD-SUDs
Male veterans were at least partially in
alcohol use remission if they had attended
PTSD specialty clinics > 2x/month in
addition to regularly attending substanceabuse treatment facilities at 2 years’
follow-up.
 Ouimette PC et al (2000). J Stud Alcohol, 61:247-253.
Impact of Concurrent
Treatment of PTSD-SUDs
Remission for SUDs was 3.7 times
more likely in those subjects in
treatment for PTSD during Year 1,
after controlling for outpatient
addiction treatment
 Ouimette PC et al (2003) Journal of Consulting and
Clinical Psychology, 71:410-414
Psychosocial Approaches
in PTSD with SUDs
How does one address the trauma?
Discuss the trauma-related deficits
Discuss the events of the trauma
Discuss the meaning of the trauma
All or some
Psychosocial Approaches
in PTSD with SUDs
When does one address the trauma?
Never
First
Last
Throughout
Integrated Treatments for PTSD –
Substance Use Disorders
Several clinical approaches described, most for
outpatients, 1 residential-based treatment
Donovan et al (2001): male vets; completed
rehab for SUDS prior to treatment entry;
multiple treatment techniques used
Decreases in PTSD severity and number of days
of substance use
 Donovan, Padin-Rivera, &Kowaliw (2001) J Traumatic Stress,
14:757-772.
Research-based Psychosocial
Treatment for PTSD-SUDS
A few have been rigorously tested:
Triffleman et al: Substance Dependence
PTSD Therapy (SDPT)=Assisted Recovery
from Trauma and Substances
Najavits et al: Seeking Safety
Back, Brady et al:
Concurrent Treatment of PTSD and Cocaine
Dependence
Research-based Psychosocial
Treatment for PTSD-SUDS
Assisted Recovery from Trauma and
Substances (ARTS; as SDPT, Triffleman
et al 1998, 2000, 2001)
Manualized Cognitive-Behavioral
Treatment with careful attention to
transference and countertransference
issues
Assisted Recovery from
Trauma and Substances
Phased, sequential treatment
Throughout: weekly – twice
weekly urine toxicology screening

ARTS
Phase I (week 1-12):
Substance use-focused, trauma-informed,
with emphasis on reduction of substance
use, based on Carroll’s (1993) CognitiveBehavioral Coping Skills Therapy
PTSD psychoeducation
PTSD and addiction-related coping skills,
including relaxation training, anger
management, assertiveness among others
Tacit motivational enhancement
ARTS
Phase II (weeks 13 and on):
Stress Inoculation
Prolonged exposure, adapted for work
with the actively addicted by a) fewer
repetitions each session; b) active
discussion after each PE; c) no tapes for
homework.
ARTS
In-vivo exposure (homework)
Could be started before or after onset of
prolonged exposure, based on individual
needs and comprehension
Continued urine tox testing, continued
therapist active query and attention to
substance use, craving, triggers
(including treatment sessions) etc.
ARTS
5 months duration
Twice-weekly hour-long sessions
Individual therapy
 Outpatients
Research-based Psychosocial
Treatments for PTSD-SUDs
Najavits et al 1996: Seeking Safety
Integrative method based on Judith
Herman’s work
12-week, group therapy, 1.5 hours 2x/week
Emphasis on cognitive and coping skills
approaches
No direct discussion of the specifics of
traumatic events
Research-based Psychosocial
Treatments for PTSD-SUDs
Back, Brady et al (2001): 12-week
Concurrent Treatment of PTSD and
Cocaine Dependence
4 weeks of introduction, relapse
prevention and PTSD psychoeduction
Prolonged Exposure run concurrently
with cont’d relapse prevention
Commonalities among
Psychosocial approaches
to PTSD-SUDS
Structure
Gentle but firm limit-setting
Active monitoring of substance use,
PTSD symptoms, associated other
problems
Maintaining the focus, not just crisis
management
Commonalities among
Psychosocial approaches
to PTSD-SUDS
On-going, regularly scheduled
supervision
Videotaped therapy sessions
Research Trials
Triffleman (2000, 2001): Subjects in
ARTS attend more sessions over more
weeks
Substance abuse outcomes and PTSD
severity decreases equally in
comparison with Twelve-step
Facilitation therapy (Nowinski, Baker &
Carroll, 1993)
Research Trials
In order to examine PTSD-specific
components, pilot trial contrasted ARTS
with Cognitive-Behavioral Coping Skills
Therapy (CBT; Carroll et al, 1993, 1998)
for substance use disorders in a sample of
opiate dependent civilians receiving
opiate-agonist medical maintenance
ARTS vs CBCST: Major
Inclusion Criteria
Have a lifetime substance dependence
disorder on SCID
Self-reporting > 1 day of substance use
in the past 30 days –or– having a
positive urine toxicology screen
Full lifetime PTSD and current full or
partial PTSD (2/3 symptom clusters) on
the CAPS
ARTS vs CBCST: Major
Exclusion Criteria
Unable/unwilling/contraindicated to
discontinue current other psychosocial
treatment
Imminently suicidal, homicidal
Acutely manic, chronically psychotic
ARTS vs CBCST: Baseline
characteristics
Demographics (N=36):
Mean age: 44 + 8 years old
56% female
47% African-American, 35% Caucasian
80% unemployed
32% on probation or parole
ARTS vs CBCST: Baseline
characteristics
83% designated heroin as major problem
substance on the ASI
Mean: 4.1 + 1.9 lifetime substance
dependence disorders
ARTS vs CBCST: Baseline
characteristics
Index traumas: Traumatic bereavement
(16), Interpersonal victimization (11),
Witnessed interpersonal victimization
(6), Other (3)
Mean baseline CAPS severity: 65.7+
21.7; 78% had full current PTSD
ARTS vs CBCST: Outcomes
ARTS subjects attended more sessions
(mean: 26.1 +10.1) than CBCST subjects
(mean=18.8+ 10.7; Log-rank 7.83,
p<.005)
Including more sessions during the
PTSD-focused phase (10.5+ 5.0 sessions)
than CBCST (5.9+ 5.2; Breslow=6.31,
p=.01)
ARTS vs CBCST: Outcomes
CAPS PTSD severity declined over time
(F=46.64, df=1,247, p<.0001)
Declines vs baseline during follow-up
were 39-43% in both conditions
Effect sizes from 1.25 – 1.61; ARTS
ES at 18 month follow-up was 2.25.
ARTS vs CBT
ARTS vs CBCST: Outcomes
On the self-administered Posttraumatic
Diagnosis Scale, both conditions showed
net declines
Group (F=5.46, df=1,37, p=.02), time
(F=64.98, df=1,682, p<.0001) and
group-by-time effects (F=8.52, df=1, 682,
p<.005) present.
ARTS vs CBCST: Outcomes
ARTS had fewer heroin-positive urine
toxicology screens (44%) vs CBCST
(55%; log-rank =7.45, p<.01)
No differences in numbers of stimulantpositive tox screens (54% throughout the
protocol)
ARTS vs CBCST: Outcomes
ASI drug composite severity scores
showed decreases
 ASI drug composite severity scores were
associated with the interaction of time
((F=3.67, df=1,262, p=.05) and whether
the subject was receiving opiate agonist
medical maintenance (F=36.26,
df=1,271, p<.0001)
ARTS vs CBCST: Conclusions
Subjects preferentially remained in ARTS
despite the presence of exposure-based
treatment techniques
Subjects improved in PTSD severity in
both conditions, but with differences in
time course on the PDS
ARTS vs CBCST: Conclusions
Subjects in ARTS showed fewer heroinpositive urine toxicology screens, perhaps
as a function of remaining in treatment
Subjective reports regarding drug use
were affected by whether subjects were on
or off opiate-agonist maintenance
Other PTSD-SUDS
Research Trials
Najavits (1996): Open, uncontrolled trial of
N=17 treatment completers showed
decreases in PTSD severity
Hien (2000): N=100, comparing Seeking
Safety and Cognitive-Behavioral Coping
Skills Therapy: equivalent outcomes
through 6-month follow-up; return to
baseline at 9 months
Back, Brady et al (2001): uncontrolled trial,
high rates of drop-out within first four
weeks
Vicarious Traumatization
Can occur in anyone with sufficient
exposure
Those with less training are more at risk
Preventative strategies:
Talk, talk, talk: get supervision, talk with a
work-buddy, talk with religious/spiritual leader
or peers, friends, etc.
Good Self-care habits
Conclusions
PTSD-SUD is:
Commonly occurring
Often associated with other disorders
Difficult but feasible to treat with a
variety of methodologies