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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 Outline of Presentation: I. Diagnosis and Screening II. Epidemiology and Comorbidity III. Treatment Approaches 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…. 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. 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 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 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 DSM-IV Post-traumatic Stress Disorder (PTSD) At least 2 symptoms of hyperarousal; Sleep disturbances Hyperstartle Irritability or anger outbursts Hypervigilance Decreased concentration DSM-IV Post-traumatic Stress Disorder (PTSD) Duration and Impairment Criteria: Occurring > 1 month post-trauma Lasting > 1 month Interfering with function 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 Diagnostic Instruments Interviews: Clinician Administered PTSD Scale Structured Clinical Interview for DSM-IV (SCID) PTSD module Structured Interview for PTSD 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 Outline of Presentation: I. Terminology II. Epidemiology and Comorbidity III. Neurobiology and Treatment Approaches 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 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) 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 PTSDvets smoked >25 cigs per day Medical problems and PTSD Higher rate of medical problems, including: HTN Chronic pain disorders Heart disease GI disorders 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 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 Outline of Presentation: I. Diagnosis and Screening II. Epidemiology and Comorbidity III. Neurobiology and Treatment Approaches Neurobiology of PTSD Increased catecholamines, decreased alpha-2 adrenergic receptors HPA disturbances: decreased glutocorticoid levels, increased glutocorticoid receptors Increased central corticotropin-releasing factor Neurobiology of PTSD Serotonergic dysfunction Reduced beta-endorphin levels and increased pain thresholds Brain Activation Changes in PTSD Hendler et al (2003) NeuroImage, 19: 587-600 Psychopharmacological Approaches to PTSD 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 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 substanceinduced psychiatric symptoms Psychopharmacological Approaches In PTSD, medications are part of an integrative strategy As with psychotherapy, everything has been tried Psychopharmacological Approaches Antidepressants RCT’s done in PTSD on: SSRI’s (Fluoxetine, Paroxetine, Sertraline) SSNRI (Mirtazapine) TCA (Amitryptyline, Imipramine) MAOI (Phenelzine, brofaromine) Psychopharmacological Approaches Mood-stabilizing anticonvulsants (antiglutaminergic): RCT on lamotrigine Atypical antipsychotics RCT’s on risperidone, quetiapine Psychopharmacological Approaches Anti-adrenergic agents RCT on Prazosin Clonidine used frequently in children Psychopharmacological Approaches Benzodiazepines: 1 RCT: Alprazolam vs placebo, 3.75 mg qD: no effect on core PTSD symptoms 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 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 12week trial in 6 treatment-completers. Brady et al (1995) J Clin Psychiatry 56:502-505 Psychosocial Treatment 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 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 substanceabuse treatment facilities at 2 years’ follow-up. Ouimette PC et al (2000). J Stud Alcohol, 61:247-253. 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 Psychosocial Approaches in 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 Psychosocial Approaches in PTSD with SUDs When does one address the trauma? Never First Last Throughout 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. 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 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 Assisted Recovery from Trauma and Substances Phased, sequential treatment Throughout: weekly – twice weekly urine toxicology screening ARTS Phase I (week 1-12): Substance use-focused, trauma-informed, with emphasis on reduction of substance use, based on Carroll’s (1993) CognitiveBehavioral Coping Skills Therapy PTSD psychoeducation PTSD and addiction-related coping skills, including relaxation training, anger management, assertiveness among others Tacit motivational enhancement 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. 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. ARTS 5 months duration Twice-weekly hour-long sessions Individual therapy Outpatients 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 Research-based Psychosocial Treatments for PTSD-SUDs Back, Brady et al (2001): 12-week Concurrent Treatment of PTSD and Cocaine Dependence 4 weeks of introduction, relapse prevention and PTSD psychoeduction Prolonged Exposure run concurrently with cont’d relapse prevention Commonalities among Psychosocial approaches to PTSD-SUDS Structure Gentle but firm limit-setting Active monitoring of substance use, PTSD symptoms, associated other problems Maintaining the focus, not just crisis management Commonalities among Psychosocial approaches to PTSD-SUDS On-going, regularly scheduled supervision Videotaped therapy sessions Research Trials Triffleman (2000, 2001): Subjects in ARTS attend more sessions over more weeks Substance abuse outcomes and PTSD severity decreases equally in comparison with Twelve-step Facilitation therapy (Nowinski, Baker & Carroll, 1993) Research Trials In order to examine PTSD-specific components, pilot trial contrasted ARTS with Cognitive-Behavioral Coping Skills Therapy (CBT; Carroll et al, 1993, 1998) for substance use disorders in a sample of opiate dependent civilians receiving opiate-agonist medical maintenance ARTS vs CBCST: Major Inclusion Criteria Have a lifetime substance dependence disorder on SCID Self-reporting > 1 day of substance use in the past 30 days –or– having a positive urine toxicology screen Full lifetime PTSD and current full or partial PTSD (2/3 symptom clusters) on the CAPS ARTS vs CBCST: Major Exclusion Criteria Unable/unwilling/contraindicated to discontinue current other psychosocial treatment Imminently suicidal, homicidal Acutely manic, chronically psychotic ARTS vs CBCST: Baseline characteristics Demographics (N=36): Mean age: 44 + 8 years old 56% female 47% African-American, 35% Caucasian 80% unemployed 32% on probation or parole ARTS vs CBCST: Baseline characteristics 83% designated heroin as major problem substance on the ASI Mean: 4.1 + 1.9 lifetime substance dependence disorders ARTS vs CBCST: Baseline characteristics Index traumas: Traumatic bereavement (16), Interpersonal victimization (11), Witnessed interpersonal victimization (6), Other (3) Mean baseline CAPS severity: 65.7+ 21.7; 78% had full current PTSD ARTS vs CBCST: Outcomes ARTS subjects attended more sessions (mean: 26.1 +10.1) than CBCST subjects (mean=18.8+ 10.7; Log-rank 7.83, p<.005) Including more sessions during the PTSD-focused phase (10.5+ 5.0 sessions) than CBCST (5.9+ 5.2; Breslow=6.31, p=.01) ARTS vs CBCST: Outcomes CAPS PTSD severity declined over time (F=46.64, df=1,247, p<.0001) Declines vs baseline during follow-up were 39-43% in both conditions Effect sizes from 1.25 – 1.61; ARTS ES at 18 month follow-up was 2.25. ARTS vs CBT ARTS vs CBCST: Outcomes On the self-administered Posttraumatic Diagnosis Scale, both conditions showed net declines Group (F=5.46, df=1,37, p=.02), time (F=64.98, df=1,682, p<.0001) and group-by-time effects (F=8.52, df=1, 682, p<.005) present. ARTS vs CBCST: Outcomes ARTS had fewer heroin-positive urine toxicology screens (44%) vs CBCST (55%; log-rank =7.45, p<.01) No differences in numbers of stimulantpositive tox screens (54% throughout the protocol) ARTS vs CBCST: Outcomes ASI drug composite severity scores showed decreases ASI drug composite severity scores were associated with the interaction of time ((F=3.67, df=1,262, p=.05) and whether the subject was receiving opiate agonist medical maintenance (F=36.26, df=1,271, p<.0001) ARTS vs CBCST: Conclusions Subjects preferentially remained in ARTS despite the presence of exposure-based treatment techniques Subjects improved in PTSD severity in both conditions, but with differences in time course on the PDS ARTS vs CBCST: Conclusions Subjects in ARTS showed fewer heroinpositive urine toxicology screens, perhaps as a function of remaining in treatment Subjective reports regarding drug use were affected by whether subjects were on or off opiate-agonist maintenance Other PTSD-SUDS Research Trials Najavits (1996): Open, uncontrolled trial of N=17 treatment completers showed decreases in PTSD severity Hien (2000): N=100, comparing Seeking Safety and Cognitive-Behavioral Coping Skills Therapy: equivalent outcomes through 6-month follow-up; return to baseline at 9 months Back, Brady et al (2001): uncontrolled trial, high rates of drop-out within first four weeks Vicarious Traumatization Can occur in anyone with sufficient exposure Those with less training are more at risk Preventative strategies: Talk, talk, talk: get supervision, talk with a work-buddy, talk with religious/spiritual leader or peers, friends, etc. Good Self-care habits Conclusions PTSD-SUD is: Commonly occurring Often associated with other disorders Difficult but feasible to treat with a variety of methodologies