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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

ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER

Joe E. Thornton, M.D.

Alcohol Medical Scholars Program @ 2003

significance
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

dilemma
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

lecture overview
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

alcohol use spectrum
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

alcoholism definition
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

alcohol dependence
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

alcohol abuse
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

alcoholism prevalence
Alcoholism Prevalence
  • Abuse
    • Men 13 %
    • Women 6 %
  • Dependence
    • Men 20 %
    • Women 8 %

Alcohol Medical Scholars Program @ 2003

clinical course
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

clinical course11
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

medical morbidity
Medical Morbidity
  • Dependence cuts 15 years off the lifespan
  • Deaths from
    • Heart disease
    • Cancer
    • Accidents
    • Suicide

Alcohol Medical Scholars Program @ 2003

psychiatric symptoms in alcoholism
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

trauma spectrum
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

ptsd definition
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

ptsd definition16
PTSD Definition

Re-experienced as 1+ symptoms

Arousal as evidenced by 2+ symptoms

Avoidance indicated by 3+ symptoms

Alcohol Medical Scholars Program @ 2003

ptsd definition17
PTSD Definition
  • Duration >1 month
  • Symptoms significant

Alcohol Medical Scholars Program @ 2003

ptsd prevalence
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

risks for ptsd
Risks for PTSD
  • Trauma severity
  • Prior trauma
  • Prior psychiatric history
  • Peritraumatic dissociation
  • Autonomic hyperarousal
  • Acute stress symptoms

Alcohol Medical Scholars Program @ 2003

ptsd clinical course
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

ptsd and alcoholism
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

symptoms
Insomnia

Nightmares

Irritability

GI distress

Tachycardia

Dyspnea

Tremor

Fatigue

Concentration impaired

Poor recall

Decreased interests

Emotional blunting

Symptoms

Alcohol Medical Scholars Program @ 2003

diagnostic strategies
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

alcoholism treatment
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

ptsd treatment
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

alcoholism and ptsd wait and treat
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

alcoholism and ptsd comprehensive treatment
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

treatment in primary care
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

alcoholism treatment in primary care
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

brief treatment
Brief Treatment
  • Risk behavior education interventions
  • Stage specific messages
    • Abstinent
    • Non-problem use
    • At-risk use
    • Abuse, dependence

Alcohol Medical Scholars Program @ 2003

counseling fernss
Counseling (FERNSS)
  • Feedback
  • Education
  • Recommendation
  • Negotiation
  • Secure agreement
  • Set follow-up

Alcohol Medical Scholars Program @ 2003

summary
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

ad