ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER

1. ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER Joe E. Thornton, M.D. Alcohol Medical Scholars Program @ 2003

2. 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

3. 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

4. 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

5. Alcohol Use Spectrum NON-PROBUSE AT-RISKUSE ABST ABUSE DEP Use Consequences Repetition Loss of control, preoccupation, compulsivity, physical dependence - - - + -/+ - + + + + - - + ++ + + Alcohol Medical Scholars Program @ 2003

6. 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

7. 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

8. 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

9. Alcoholism Prevalence • Abuse • Men 13 % • Women 6 % • Dependence • Men 20 % • Women 8 % Alcohol Medical Scholars Program @ 2003

10. 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

11. 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

12. Medical Morbidity • Dependence cuts 15 years off the lifespan • Deaths from • Heart disease • Cancer • Accidents • Suicide Alcohol Medical Scholars Program @ 2003

13. 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

14. Trauma Spectrum Acute Stress Disorder Transient or no symptoms + PTSD None + +++ ++ ++ + + + + + + -/+ - + + - - - Trauma Consequences Impairment > 30d Re-experience, arousal and avoidant symptoms Co-occurring syndromes Alcohol Medical Scholars Program @ 2003

15. 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

16. PTSD Definition Re-experienced as 1+ symptoms Arousal as evidenced by 2+ symptoms Avoidance indicated by 3+ symptoms Alcohol Medical Scholars Program @ 2003

17. PTSD Definition • Duration >1 month • Symptoms significant Alcohol Medical Scholars Program @ 2003

18. 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

19. Risks for PTSD • Trauma severity • Prior trauma • Prior psychiatric history • Peritraumatic dissociation • Autonomic hyperarousal • Acute stress symptoms Alcohol Medical Scholars Program @ 2003

20. 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

21. 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

22. Insomnia Nightmares Irritability GI distress Tachycardia Dyspnea Tremor Fatigue Concentration impaired Poor recall Decreased interests Emotional blunting Symptoms Alcohol Medical Scholars Program @ 2003

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Brief Treatment • Risk behavior education interventions • Stage specific messages • Abstinent • Non-problem use • At-risk use • Abuse, dependence Alcohol Medical Scholars Program @ 2003

31. Counseling (FERNSS) • Feedback • Education • Recommendation • Negotiation • Secure agreement • Set follow-up Alcohol Medical Scholars Program @ 2003

32. 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