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ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER Joe E. Thornton, M.D. Alcohol Medical Scholars Program @ 2003 1 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 2 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 3 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 4 Alcohol Use Spectrum Use Consequences Repetition ABST NONPROB USE - + - ATRISK ABUSE DEP USE + -/+ - + + + + ++ + Loss of control, preoccupation, compulsivity, physical dependence + Alcohol Medical Scholars Program @ 2003 5 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 6 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 7 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 8 Alcoholism Prevalence Abuse Men 13 % Women 6 % Dependence Men 20 % Women 8 % Alcohol Medical Scholars Program @ 2003 9 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 10 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 11 Medical Morbidity Dependence cuts 15 years off the lifespan Deaths from Heart disease Cancer Accidents Suicide Alcohol Medical Scholars Program @ 2003 12 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 13 Trauma Spectrum Acute Transient Stress PTSD or no None Disorder symptoms + -/+ - + + - Trauma Consequences Impairment > 30d Re-experience, arousal and avoidant symptoms Co-occurring syndromes Alcohol Medical Scholars Program @ 2003 + + + + + + +++ ++ ++ + 14 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 15 PTSD Definition Re-experienced as 1+ symptoms Arousal as evidenced by 2+ symptoms Avoidance indicated by 3+ symptoms Alcohol Medical Scholars Program @ 2003 16 PTSD Definition Duration >1 month Symptoms significant Alcohol Medical Scholars Program @ 2003 17 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 18 Risks for PTSD Trauma severity Prior trauma Prior psychiatric history Peritraumatic dissociation Autonomic hyperarousal Acute stress symptoms Alcohol Medical Scholars Program @ 2003 19 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 20 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 21 Symptoms Insomnia Nightmares Irritability GI distress Tachycardia Dyspnea Tremor Fatigue Concentration impaired Poor recall Decreased interests Emotional blunting Alcohol Medical Scholars Program @ 2003 22 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 23 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 24 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 25 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 26 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 27 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 28 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 29 Brief Treatment Risk behavior education interventions Stage specific messages Abstinent Non-problem use At-risk use Abuse, dependence Alcohol Medical Scholars Program @ 2003 30 Counseling (FERNSS) Feedback Education Recommendation Negotiation Secure agreement Set follow-up Alcohol Medical Scholars Program @ 2003 31 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 32