1 / 74

Post-traumatic Stress Disorder in Addictions

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.

edison
Download Presentation

Post-traumatic Stress Disorder in Addictions

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Post-traumatic Stress Disorder in Addictions Elisa Triffleman, MD The Public Health Institute, Berkeley, CA Yale University School of Medicine, New Haven, CT

  2. Outline of Presentation: • I. Diagnosis and Screening • II. Epidemiology and Comorbidity • III. Neurobiology and Treatment Approaches

  3. Outline of Presentation: • I. Diagnosis and Screening • II. Epidemiology and Comorbidity • III. Treatment Approaches

  4. 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….

  5. 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.

  6. 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

  7. 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

  8. 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

  9. DSM-IV Post-traumatic Stress Disorder (PTSD) • At least 2 symptoms of hyperarousal; • Sleep disturbances • Hyperstartle • Irritability or anger outbursts • Hypervigilance • Decreased concentration

  10. DSM-IV Post-traumatic Stress Disorder (PTSD) • Duration and Impairment Criteria: • Occurring > 1 month post-trauma • Lasting > 1 month • Interfering with function

  11. 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

  12. Diagnostic Instruments • Interviews: • Clinician Administered PTSD Scale • Structured Clinical Interview for DSM-IV (SCID) PTSD module • Structured Interview for PTSD

  13. 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

  14. Outline of Presentation: • I. Terminology • II. Epidemiology and Comorbidity • III. Neurobiology and Treatment Approaches

  15. 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

  16. 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)

  17. 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 PTSD- vets smoked >25 cigs per day

  18. Medical problems and PTSD • Higher rate of medical problems, including: • HTN • Chronic pain disorders • Heart disease • GI disorders

  19. 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

  20. 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

  21. Outline of Presentation: • I. Diagnosis and Screening • II. Epidemiology and Comorbidity • III. Neurobiology and Treatment Approaches

  22. Neurobiology of PTSD • Increased catecholamines, decreased alpha-2 adrenergic receptors • HPA disturbances: decreased glutocorticoid levels, increased glutocorticoid receptors • Increased central corticotropin-releasing factor

  23. Neurobiology of PTSD • Serotonergic dysfunction • Reduced beta-endorphin levels and increased pain thresholds

  24. Brain Activation Changes in PTSD Hendler et al (2003) NeuroImage, 19: 587-600

  25. Psychopharmacological Approaches to PTSD

  26. 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

  27. 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 substance-induced psychiatric symptoms

  28. Psychopharmacological Approaches • In PTSD, medications are part of an integrative strategy • As with psychotherapy, everything has been tried

  29. Psychopharmacological Approaches • Antidepressants • RCT’s done in PTSD on: • SSRI’s (Fluoxetine, Paroxetine, Sertraline) • SSNRI (Mirtazapine) • TCA (Amitryptyline, Imipramine) • MAOI (Phenelzine, brofaromine)

  30. Psychopharmacological Approaches • Mood-stabilizing anticonvulsants (anti-glutaminergic): • RCT on lamotrigine • Atypical antipsychotics • RCT’s on risperidone, quetiapine

  31. Psychopharmacological Approaches • Anti-adrenergic agents • RCT on Prazosin • Clonidine used frequently in children

  32. Psychopharmacological Approaches • Benzodiazepines: • 1 RCT: Alprazolam vs placebo, 3.75 mg qD: no effect on core PTSD symptoms

  33. 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

  34. 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 12-week trial in 6 treatment-completers. • Brady et al (1995) J Clin Psychiatry 56:502-505

  35. Psychosocial Treatment

  36. 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

  37. 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 substance-abuse treatment facilities at 2 years’ follow-up. • Ouimette PC et al (2000). J Stud Alcohol, 61:247-253.

  38. 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

  39. Psychosocial Approachesin 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

  40. Psychosocial Approachesin PTSD with SUDs • When does one address the trauma? • Never • First • Last • Throughout

  41. 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.

  42. 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

  43. 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

  44. Assisted Recovery from Trauma and Substances • Phased, sequential treatment • Throughout: weekly – twice weekly urine toxicology screening

  45. ARTS • Phase I (week 1-12): • Substance use-focused, trauma-informed, with emphasis on reduction of substance use, based on Carroll’s (1993) Cognitive-Behavioral Coping Skills Therapy • PTSD psychoeducation • PTSD and addiction-related coping skills, including relaxation training, anger management, assertiveness among others • Tacit motivational enhancement

  46. 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.

  47. 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.

  48. ARTS • 5 months duration • Twice-weekly hour-long sessions • Individual therapy • Outpatients

  49. 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

More Related