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ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER Joe E. Thornton, M.D. Significance Alcoholism and Posttraumatic Stress Disorder (PTSD) are common Symptoms overlap Co-occurrence increases severity Most physicians know little about either but will treat at-risk patients Dilemma

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Alcoholism and posttraumatic stress disorder l.jpg

ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER

Joe E. Thornton, M.D.

Alcohol Medical Scholars Program @ 2003


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Significance

  • Alcoholism and Posttraumatic Stress Disorder (PTSD) are common

  • Symptoms overlap

  • Co-occurrence increases severity

  • Most physicians know little about either but will treat at-risk patients

Alcohol Medical Scholars Program @ 2003


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Dilemma

  • People may increase alcohol use in response to trauma

  • Alcoholism could temporarily mimic PTSD

  • Alcoholism makes preexisting disorders (including PTSD) worse

Alcohol Medical Scholars Program @ 2003


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Lecture Overview

  • Clinical information on alcoholism

  • Clinical information on PTSD

  • Strategies for diagnoses and treatment

  • Strategies for primary care treatment interventions

Alcohol Medical Scholars Program @ 2003


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Alcohol Use Spectrum

NON-PROBUSE

AT-RISKUSE

ABST

ABUSE

DEP

Use

Consequences

Repetition

Loss of control, preoccupation, compulsivity, physical dependence

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Alcohol Medical Scholars Program @ 2003


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Alcoholism Definition

  • Alcoholism = Alcohol Use Disorders

  • DSM-IV Alcohol Use Disorders

    • Alcohol dependence

    • Alcohol abuse

    • Alcoholism may be complicated by alcohol induced disorders

Alcohol Medical Scholars Program @ 2003


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Alcohol Dependence

In the past 12 months 3+ of:

  • Tolerance

  • Withdrawal

  • More use

  • Loss of control

  • Significant time

  • Giving up important activities

  • Continued use

Alcohol Medical Scholars Program @ 2003


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Alcohol Abuse

Repetitive pattern of harmful behaviors 1+ of:

  • Failure to fulfill major role obligations

  • Physically hazardous use

  • Legal problems related to use

  • Interpersonal problems related to use

Alcohol Medical Scholars Program @ 2003


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Alcoholism Prevalence

  • Abuse

    • Men 13 %

    • Women 6 %

  • Dependence

    • Men 20 %

    • Women 8 %

Alcohol Medical Scholars Program @ 2003


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Clinical Course

Early milestones similar to population

  • First drink ~age 13

  • First intoxication ~age 16

  • First problem ~age 21

  • 40% of all drinkers have some minor problem at some time

Alcohol Medical Scholars Program @ 2003


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Clinical Course

  • Dependence ~age 28

  • Variable course

  • Frequent periods of abstinence

  • Any given month ~50% of alcoholics are abstinent

  • Spontaneous remissions ~20%

Alcohol Medical Scholars Program @ 2003


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Medical Morbidity

  • Dependence cuts 15 years off the lifespan

  • Deaths from

    • Heart disease

    • Cancer

    • Accidents

    • Suicide

Alcohol Medical Scholars Program @ 2003


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Psychiatric Symptoms in Alcoholism

  • Almost 100% have insomnia and bad dreams

  • ~ 40% experience

    • Depression

    • Anxiety

    • Psychosis

    • Other alcohol induced disorders

  • Symptoms resolve with abstinence

Alcohol Medical Scholars Program @ 2003


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Trauma Spectrum

Acute Stress Disorder

Transient or no symptoms

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PTSD

None

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Trauma

Consequences

Impairment > 30d

Re-experience, arousal and avoidant symptoms

Co-occurring syndromes

Alcohol Medical Scholars Program @ 2003


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PTSD Definition

DSM-IV Posttraumatic stress disorder

History of traumatic event:

  • Person experienced, witnessed, or was confronted with a disturbing event

  • Response was intense fear, helplessness, or horror

Alcohol Medical Scholars Program @ 2003


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PTSD Definition

Re-experienced as 1+ symptoms

Arousal as evidenced by 2+ symptoms

Avoidance indicated by 3+ symptoms

Alcohol Medical Scholars Program @ 2003


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PTSD Definition

  • Duration >1 month

  • Symptoms significant

Alcohol Medical Scholars Program @ 2003


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PTSD Prevalence

  • ~70% persons in US exposed to 1+ trauma

  • ~11% of trauma-exposed persons develop PTSD

  • Prevalence of PTSD:

    • Men – 5%

    • Women – 10%

Alcohol Medical Scholars Program @ 2003


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Risks for PTSD

  • Trauma severity

  • Prior trauma

  • Prior psychiatric history

  • Peritraumatic dissociation

  • Autonomic hyperarousal

  • Acute stress symptoms

Alcohol Medical Scholars Program @ 2003


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PTSD Clinical Course

  • Onset follows Acute Stress Disorder

  • Variable course

  • Spontaneous remission uncommon

  • Physical symptoms common

  • No definitive link with physical health or mortality

Alcohol Medical Scholars Program @ 2003


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PTSD and Alcoholism

  • Community patients with PTSD have 2x alcoholism

  • Patients seeking treatment for alcoholism have 3x PTSD

  • Substance dependence adolescent inpatients have 5x PTSD

  • Inpatient alcohol rehabilitation adult women have 5x PTSD

Alcohol Medical Scholars Program @ 2003


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Insomnia

Nightmares

Irritability

GI distress

Tachycardia

Dyspnea

Tremor

Fatigue

Concentration impaired

Poor recall

Decreased interests

Emotional blunting

Symptoms

Alcohol Medical Scholars Program @ 2003


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Diagnostic Strategies

  • Age of onset alcoholism

  • Periods of abstinence

  • Age of trauma

  • ? PTSD existed before alcoholism or after 3+ months of abstinence

  • Findings dictate treatment

Alcohol Medical Scholars Program @ 2003


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Alcoholism Treatment

  • Cognitive/behavioral

    • Increase motivation

    • Help restore functioning

    • Relapse prevention

  • Intense treatment 2-4 weeks

  • Then less intense for 6+ months

  • Self-help groups

  • Limited role for medications (naltrexone)

Alcohol Medical Scholars Program @ 2003


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PTSD Treatment

  • Cognitive/behavioral (e.g. Exposure Therapy)

    • Patient confronts event

    • Patient educated about common reactions to trauma

    • Patient is trained in behavioral symptom management

    • Patient progressively masters the symptom response

  • Medications

    • SSRI antidepressants

Alcohol Medical Scholars Program @ 2003


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Alcoholism and PTSD Wait and Treat

  • Achieve abstinence and monitor PTSD symptoms

  • Control PTSD symptoms and monitor alcohol abstinence

  • Sequential treatment

    • Treat the most disabling syndrome first

    • If second syndrome still present after time then treat

Alcohol Medical Scholars Program @ 2003


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Alcoholism and PTSD Comprehensive Treatment

  • Coordinated treatments

    • Alcohol counselors communicate with therapists treating PTSD

  • Integrated treatments

    • Alcohol counselors and PTSD therapists work as a team

Alcohol Medical Scholars Program @ 2003


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Treatment in Primary Care

  • Assess symptoms

  • Assess in detail patient’s response to symptoms

    • Over the counter medicines

    • Alcohol or other substance use

  • Psychosocial history

  • Behavioral health history

Alcohol Medical Scholars Program @ 2003


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Alcoholism Treatment in Primary Care

  • Quantity /frequency interview

    • How many days a week do you drink?

    • How much on typical drinking day?

    • What is the most you had had to drink on one day?

  • Education about at-risk drinking

    • Men > 5 drink/day or 14 drinks/week

    • Women > 3 drinks/day or 7 drinks/week

Alcohol Medical Scholars Program @ 2003


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Brief Treatment

  • Risk behavior education interventions

  • Stage specific messages

    • Abstinent

    • Non-problem use

    • At-risk use

    • Abuse, dependence

Alcohol Medical Scholars Program @ 2003


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Counseling (FERNSS)

  • Feedback

  • Education

  • Recommendation

  • Negotiation

  • Secure agreement

  • Set follow-up

Alcohol Medical Scholars Program @ 2003


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Summary

  • Alcoholism and PTSD commonly co-occur

  • Diagnosis of both disorders is essential for successful treatment

  • Comprehensive treatment incorporates the interactions of symptoms with treatment

  • All physicians have treatment opportunities

Alcohol Medical Scholars Program @ 2003


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