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Treating offenders with substance Abuse and posttraumatic stress disorder

Treating offenders with substance Abuse and posttraumatic stress disorder. Douglas L. Delahanty Alec Boros Kent State University Oriana House. Overview. Introduction to PTSD Comorbidity of PTSD/SUD Intervention: Prolonged Exposure

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Treating offenders with substance Abuse and posttraumatic stress disorder

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  1. Treating offenders with substance Abuse and posttraumatic stress disorder Douglas L. Delahanty Alec Boros Kent State University Oriana House

  2. Overview • Introduction to PTSD • Comorbidity of PTSD/SUD • Intervention: Prolonged Exposure • Using PE with SUD Clients • The KSU-Oriana House Studies on PTSD • Challenges of treating offenders in community corrections • Alternatives for treatment in Community Corrections

  3. Introduction to PTSD

  4. DSM-IV Diagnostic Criteria for PTSD • Exposure to a traumatic event in which the person: • experienced, witnessed, or was confronted by death or serious injury to self or others AND • responded with intense fear, helplessness, or horror • Symptoms • appear in 3 symptom clusters: re-experiencing, avoidance/numbing, hyperarousal • last for > 1 month • cause clinically significant distress or impairment in functioning American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.

  5. DSM-IV Diagnostic Criteria for PTSD • Reexperiencing • Persistent re-experiencing of  1 of the following: • recurrent distressing recollections of event • recurrent distressing dreams of event • acting or feeling event was recurring • psychological distress at cues resembling event • physiological reactivity to cues resembling event American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.

  6. DSM-IV Diagnostic Criteria for PTSD • Avoidance and Numbing • Avoidance of stimuli and numbing of general responsiveness indicated by  3 of the following: • avoid thoughts, feelings, or conversations • avoid activities, places, or people • inability to recall part of trauma •  interest in activities • estrangement from others • restricted range of affect • sense of foreshortened future American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.

  7. DSM-IV Diagnostic Criteria for PTSD • Hyperarousal • Persistent symptoms of increased arousal  2: • difficulty sleeping • irritability or outbursts of anger • difficulty concentrating • hypervigilance • exaggerated startle response American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.

  8. DSM 5 PTSD Criteria • As of May 2013, the DSM 5 has contained slightly different PTSD diagnostic criteria • Symptoms are mostly the same • The 3 clusters of DSM-IV symptoms will be divided into 4 clusters in DSM-5: intrusion symptoms, avoidance symptoms, arousal/reactivity symptoms and negative mood and cognitions. • Criterion A2 (requiring fear, helplessness or horror happen right after the trauma) will be removed. • Based on the proposed DSM-5 criteria, the prevalence of PTSD will be similar to what it is currently in DSM-IV.

  9. Incidence of PTSD • 69% of civilians report experiencing a traumatic event (Norris, 1992; Resnick et al., 1993) • Affects more than 10 million American children or adults (National Center for PTSD, 2001) • Lifetime prevalence in the U.S. is 6.8%, making it the third most common anxiety disorder (Kessler et al., 2005) • Females are at approximately 2x greater risk than males

  10. Prevalence of Trauma and Probability of PTSD Witness Accident Threat w/ Weapon Physical Attack Molestation Combat Rape Kessler R et al. J Clin Psychiatry. 2000;61(Suppl 5):4-14. Kessler R et al. Arch Gen Psychiatry. 1995;52:1048-1060.

  11. Consequences of PTSD • Negative impact on affect regulation, attention, cognition, interpersonal relationships and neuroendocrinology (Hart et al.,1995; Maughan & Cicchetti, 2002; Putnam et al., 1997) • Increased risk for: • Physical health problems (Pacella, Hruska, & Delahanty, 2013) • Unemployment (Smith, Schnurr, Rosenheck, 2005) • Relationship problems (Riggs, Byrne, Weathers, & Litz, 1998) • Suicide (Marshall et al., 2001)

  12. Psychiatric Comorbidity in PTSD

  13. Psychiatric Comorbidity in PTSD (Pietrzak, Goldstein, Southwick, & Grant, 2011)

  14. Psychiatric Comorbidity in PTSD Comorbidity (%) Social Anxiety Disorder MajorDepressive Episode Agora phobia AlcoholAbuse/ Dependence DrugAbuse/ Dependence PanicDisorder GAD Kessler R et al. Arch Gen Psychiatry. 1995; 52:1048-1060.

  15. SUD-PTSD Comorbidity • 46.4% of people with PTSD meet criteria for one or more SUDs (Pietrzak, Goldstein, Southwick, & Grant, 2011) • Comorbidity rates of substance abuse/dependence in PTSD are high (up to 43%) (Breslau, Davis, & Schultz, 2003; Deering, Glover, Ready, Edelman, & Alarcon, 1996; Friedman, 1991; Friedman & Yehuda, 1995; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). • PTSD rates range from 30-50% in substance abusers (Dansky, Roitzsch, Brady, & Saladin, 1997; Mills, Lynskey, Teesson, Ross, & Darke, 2005) • 253 Australian detox inpatients (Dore et al., 2012) • 80% experienced > 1 trauma • 45% screened for PTSD

  16. PTSD-SUD is associated with significant impairment • More severe alcohol problems (McFall, MacKay, & Donovan, 1992) • Greater utilization of addiction treatment services (Brown, Stout, & Mueller, 1999) • Higher relapse rates, poorer treatment outcomes(Jacobsen et al., 2001; Read et al., 2004) • More severe PTSD symptoms (Hien, Campbell, Ruglass, Hu, & Killeen, 2011; Saladin, Brady, Dansky, & Kilpatrick, 1995)

  17. PTSD-SUD is associated with significant impairment, cont’d • Less successful PTSD treatment (Perconte & Giger, 1991) • Greater medical, social and employment costs than either disorder alone (Neuman et al., 2012; Brady et al., 2004; Brown et al., 1994) • Psychiatric comorbidity in SUD patients can serve as a barrier to successful SUD engagement and treatment at every stage of the process

  18. Theories of Comorbidity: SUD and PTSD • The self-medication hypothesis • The high risk hypothesis • The susceptibility hypothesis • The substance-induced anxiety enhancement • hypothesis • The shared vulnerability hypothesis • Stewart & Conrod, 2008; Hruska and Delahanty, in press

  19. Comorbidity Theory: Self-Medication Hypothesis • PTSD temporally precedes SUD and leads to the development of substance use problems as the individual attempts to self-medicate the negative affect associated with their trauma symptoms.

  20. Comorbidity Theory: High Risk Hypothesis • Substance use puts one at risk for exposure to traumatic events and subsequently, PTSD. Substance use precedes PTSD.

  21. Comorbidity Theory: Susceptibility Hypothesis • The use of substances increases the likelihood of developing PTSD following a traumatic event. Substance use precedes PTSD.

  22. Comorbidity Theory: Substance-induced anxiety enhancement hypothesis • SUD leads to the development of PTSD symptoms following trauma because SUDs affect the functioning of the body’s stress response system

  23. Comorbidity Theory: Shared vulnerability hypothesis • PTSD and SUD onset occur near the same time due to a shared vulnerability (genetic/physiological/ underlying risk factors) common to the development of both disorders

  24. Tension Reduction Model • Neuroendocrine, neuroanatomical, and genetic research support the tension reduction model (Hruska & Delahanty, in press) • Trauma or PTSD diagnosis precedes the onset of alcohol or substance abuse (Bremner et al., 1996; Clark & Jacob, 1992; Davidson et al., 1985, 1990) • Having PTSD increased the risk of developing a subsequent SUD, but presence of drug abuse or dependence did not substantially increase risk for developing PTSD (Chilcoat and Breslau, 1998) • PTSD symptoms mediate the relationship between prior trauma and alcohol use in adult women (Epstein, Saunders, Kilpatrick, & Resnick, 1998).

  25. Tension Reduction Model • As trauma victims with PTSD may self-medicate with substances to decrease the intensity of PTSD symptoms, decreasing PTSD symptoms through empirically supported therapies may be associated with a decrease in substance use/abuse. • Failure to address underlying PTSD symptoms results in greater SUD relapse rates, further reinforcing the importance of addressing psychopathological barriers to SUD treatment success (Brown et al., 1999)

  26. Intervention: Prolonged Exposure

  27. Prolonged exposure therapy (PE) • PE therapy has been found to be effective in the treatment of PTSD and comorbid symptoms across several controlled studies • Most appropriate form of treatment for PTSD (Ballenger et al., 2000) • PE aims to reduce the fear or anxiety associated with the trauma by encouraging patients to repeatedly confront fear-evoking stimuli (Foa et al., 2007)

  28. PE: Mechanisms • Repeated imaginal exposure facilitates habituation and reduction of anxiety associated with the traumatic memory • By imagining and discussing the traumatic event with a supportive therapist, the patient begins to realize that thinking about the trauma is not dangerous

  29. PE: Mechanisms • Through imaginal exposure to the trauma memory and in vivo exposure to external cues, the patient begins to differentiate the traumatic event from other situations, decreasing generalization of fear responses • Following repeated exposure, the patient achieves a sense of mastery that contradicts the typical view of symptoms reflecting weakness

  30. Prolonged Exposure • Equally efficacious in African-Americans and Whites • Effective in treating victims from a wide range of traumas including war experiences, rape, assault, crime, and samples including victims of a variety of different traumas • Effective in treating individuals who have been multiply traumatized and patients who suffer from complex PTSD

  31. PE compared to other approaches • PE is more effective and efficient than: • relaxation training • eye movement desensitization and reprocessing (EMDR) • counseling • stress inoculation training (SIT) • combination therapy involving both PE and SIT, especially at longer-term follow-up assessments

  32. Prolonged Exposure • 10 sessions conducted twice per week for 5 weeks. • Each session lasts between 90-120 minutes. • Include education about common reactions to trauma, breathing retraining, prolonged (repeated) imaginal exposure to trauma memories, repeated in vivo exposure to situations the client is avoiding due to trauma-related fear, and discussion of thoughts and feelings related to exposure exercises.

  33. Session 1 Begins with an overview of the treatment program and a general rationale for exposure. The therapist gathers information focusing on the client’s symptoms, details of the trauma, history of previous trauma, and social and occupational functioning. Breathing retraining is introduced and the client practices breathing techniques. Homework consists of daily breathing exercises, listening to the tape of the session, and reviewing the "Rationale for Treatment" handout.

  34. Session 2 Focuses on education, treatment planning, and development of the in vivo exposure hierarchy. The therapist provides an explanation of PTSD, discusses common reactions to trauma, discusses a rationale for the treatment, and provides a description of each treatment component. The use of Subjective Units of Distress (SU) ratings is explained. A list of avoided situations is compiled and an exposure hierarchy is developed.

  35. Session 3 Reviews the rationale for PE and introduces prolonged imaginal exposure. The client is guided through 60 minutes of imaginal reliving of the focal trauma. The client is instructed to relive the trauma as vividly as possible, and to recount it aloud in the present tense. This procedure is repeated until the exposure period is expended. SU ratings are obtained every 5 minutes and vividness ratings are taken every 10 minutes.

  36. Sessions 4-9 Focus on imaginal exposure for 45-60 minutes, followed by discussion of any thoughts and feelings provoked by the reliving. During imaginal exposure, the therapist asks specific questions to clarify the client's thoughts, feelings, and physical reactions while reliving the trauma to facilitate confrontation with fear-evoking cues. The parts of the scenario that are the most anxiety-producing for the client are identified and emphasized in repeated exposure.  

  37. Session 10 (Termination) Imaginal exposure lasts 30 minutes. The therapist and client review treatment progress and discuss applications of treatment principles to daily life. This discussion will address the potential for temporary increases in PTSD symptoms, and how these can be managed. At this time, the therapist and client will evaluate progress and determine whether additional sessions or referral may be worthwhile.

  38. Using Prolonged Exposure for individuals with PTSD and Substance Abuse

  39. PE in SUD populations • Initial concern was risk for substance use relapse • six male veterans undergoing imaginal flooding therapy for PTSD, 3 out of 4 of the patients with current or past histories of alcoholism relapsed to alcohol abuse (Pitman et al., 1991) • More recent examinations of the efficacy of PE have not found consistent relationships between substance use and treatment outcome or dropout

  40. PE in SUD populations (Cont,d) • Interventions developed to treat comorbid SUD and PTSD have incorporated imaginal exposure • Exposure therapies have demonstrated efficacy in reducing PTSD severity in SUD-PTSD patients • Patients who have received PE reported fewer cravings than those who did not • We have also demonstrated the efficacy of PE in a study of HIV+ individuals, 60% of whom reported substance use at the start of the protocol

  41. PEACH Study (Pacella et al., 2012) • Examine the efficacy of PE at: • Reducing HIV related and non- HIV related PTSD symptoms in PLWH • Reducing depressive symptoms • Increasing adherence

  42. Participants • 43 participants • Age (M = 46.39) • 29 Males; 14 Females • 49% African American; 45.1% Caucasian; 5.9% Hispanic • Years living with HIV (M = 13.1; range: 1-27 years) • Income: 84% Under $20,000

  43. Pre-Screen (N = 99) Eligible (N = 65) Ineligible (N = 34) Intervention Weekly monitoring control group Baseline (N = 34) Baseline (N = 25) Post-intervention (N = 24) Post-intervention (N = 23) 3-month Follow-up (N = 19) 3-month Follow-up (N = 24)

  44. Treatment Conditions • Prolonged Exposure: • Focused on the most traumatic event they’ve experienced • 10 sessions; 5 weeks • Weekly Monitoring/Wait-list group

  45. HIV related PTSS

  46. Non-HIV related PTSS

  47. Depression

  48. Peach Study (Pacella et al., 2012): Conclusions • Overall, PE was readily accepted by PLWH and was efficacious in reducing symptoms of: • PTSS for HIV and non-HIV related trauma • Depressive symptoms • PE was not associated with exacerbation of self-reported substance use (SU). The control group went from an average of 7 instances of SU in the last week at baseline to 2 at post-intervention to 7 at 3-month follow-up, while the PE group went from 3 at baseline to 2 at post-intervention to 4.5 at 3-month follow-up. • PE and control participants did not significantly differ on adherence variables

  49. The KSU-Oriana House Studies on PTSD

  50. The KSU-Oriana House Studies • Detox patient studies: • The KSU- Summit County ADM Crisis Center Study (Hruska et al., in press) • The Life Experiences and Drug Dependence Study (Ongoing) • Prolonged Exposure and Motivational Interviewing Study (PE-MI) • Residential • Community Based Correctional Facility (Just started) • Non Residential • Summit County Felony Drug Court (grant funded, started in 2013)

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