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Brian L. Meyer, Ph.D.
Interim Associate Chief,
Mental Health Clinical Services
McGuire VA Medical Center
Richmond, VA
October 28, 2014
The views expressed in this presentation are solely
those of the presenter and do not represent those
of the Veterans Health Administration, the
Department of Defense, or the United States
Co-Occurrence of
PTSD and Substance Abuse
disorders are
the rule rather
than the
(SAMHSA, 2002)
PTSD Co-Morbidities
Kessler et al., 1995
Co-Occurrence of
 PTSD and substance abuse co-occur at a high rate
 20-40% of people with PTSD also have SUDs (SAMHSA,
 40-60% of people with SUDs have PTSD
 Substance use disorders are 3 times more
prevalent in people with PTSD than those
without PTSD
 The presence of either disorder alone increases
the risk for the development of the other
 The combination results in poorer treatment
Co-Occurring PTSD and SUDs
Make Each Other Worse
 Substance abuse exacerbates
PTSD symptoms, including sleep
disturbance, nightmares, rage,
depression, avoidance, numbing
of feelings, social isolation,
irritability, hypervigilance,
paranoia, and suicidal ideation
 People who drink or use drugs are
at risk for being retraumatized
through accidents, injuries, and
sexual trauma
PTSD and Substance Abuse
 PTSD/SUD patients have significantly greater
Other Axis I disorders
Increased psychiatric symptoms
Increased inpatient admissions
Interpersonal problems
Medical problems
Decreased motivation for treatment
Decreased compliance with aftercare
Maltreatment of children
Custody battles
HIV risk
Veterans in Prison
 By 1985, more that 1/5 prison inmates were Veterans (Daily
Beast, 7/28/13)
 By 1988, more than half of all Vietnam Veterans with PTSD
had been arrested
More than 1/3 had been arrested multiple times (NCPTSD)
 1/11 prison inmates are Veterans (DOJ, 2004)
 This is about 223,000 people
 56,000 Veterans are released from state and federal prisons
annually, and another 90,000 are released from city and
county jails (Noonan, 2010)
Veterans and Criminality
 We do not know how many Veterans of the Iraq and
Afghanistan conflicts are in prison because the last
Dept. of Justice survey was completed in 2004
 The best estimate is 9% (Elbogen et al., 2012)
 This percentage is likely to rise, since the numbers
and percentage of Veterans in prison rises after wars
 The primary reason Veterans are arrested is substance
abuse (Beckerman, et al. 2009; Erickson, et al. 2008)
 The other major reason is PTSD
 When irritability and anger are high, 23% of OEF/OIF
Veterans with PTSD have been arrested (Elbogen et al.,
Trauma and PTSD
 More men (61%) than women (51%) experience a
trauma at some point in their lives, but women
experience PTSD at twice the rate of men (10% vs. 5%)
(Kessler et al., 1995; Tolin and Foa, 2006)
 Depending on the study, the type of trauma, and the group
studied, 3%-58% get PTSD
 Therefore, not all trauma leads to PTSD
Life-Threatening Events
Who Gets PTSD?
 It depends on:
 PTSD is mitigated or worsened by:
Childhood experience
Personality characteristics
Family history
Social support
PTSD and the Brain
Amygdala – Emotional
reactions, fight or
flight alarm system
(Smaller volume)
Hippocampus – Relay
station for sorting
Prefrontal cortex –
logic, reasoning,
planning, impulse
control, organizing
Post-Traumatic Responses
Occur on a Continuum
Changes to PTSD
Diagnosis in DSM 5*
 Trauma and Stressor-Related
Disorders are placed in their own
 Loss of loved one must be traumatic
or accidental
 Elimination of B criterion of reaction
of horror, terror, or helplessness
 Military and first responders do their job
* Indicates material in packet
Changes to PTSD
Diagnosis in DSM 5
 Addition of new criteria involving
negative cognitions (negative beliefs
about the world, blame of self or others
for the trauma) and mood (depression,
anger, guilt)
 Addition of a new arousal criterion:
self-destructive or reckless behavior
 These changes result in approximately
the same number of people who will
meet criteria for a diagnosis of PTSD
Stress Disorder in DSM 5
PTSD is characterized by:
Exposure to a severe life-threatening event
Repetitive re-experiencing of the event
Avoidance of stimuli associated with trauma
Negative moods and cognitions
Increased arousal
PTSD: Exposure to a LifeThreatening Event
A. Exposure to a
traumatic event
 Exposure to death,
threatened death,
actual or threatened
serious injury, or actual
or threatened sexual
PTSD: Intrusion Symptoms
B. Intrusion symptoms:
 Recurrent, involuntary and intrusive
 Traumatic nightmares
 Dissociative reactions (e.g., flashbacks)
 Intense or prolonged distress after exposure to
traumatic reminders
 Marked physiological reactivity to traumarelated stimuli
PTSD: Avoidance of Stimuli
Associated with Traumatic Event
C. Persistent effortful
 Trauma-related
avoidance of
thoughts and feelings
distressing trauma Trauma-related
related stimuli after the
external reminders
PTSD: Negative
Cognitions and Mood
D. Negative alterations in cognitions and mood
that began or worsened after the traumatic
 Inability to recall key features of the traumatic
 Persistent negative beliefs and expectations
about self or world
 Persistent distorted blame of self or others for
causing the event or the resulting consequences
PTSD: Negative
Cognitions and Mood
 Persistent negative trauma-
related emotions (e.g., fear,
horror, anger, guilt, or shame)
 Markedly diminished interest
in significant activities
 Feeling alienated from others
 Constricted affect: persistent
inability to experience positive
PTSD: Increased Arousal
and Reactivity
E. Trauma-related alterations in arousal and
reactivity that began or worsened after the
traumatic event:
 Irritable or aggressive behavior
 Self-destructive or reckless behavior
 Hypervigilance
 Exaggerated startle response
 Problems in concentration
 Sleep disturbance
PTSD: A New Subtype
Dissociative Subtype of PTSD:
 Meets criteria for a diagnosis of PTSD
 Experiences high levels of depersonalization or
 Dissociative symptoms are not related to substance
abuse or other medical condition
Implications of Changes to
PTSD Diagnosis in DSM 5
 Angry, depressive, and anxious affects now apply
 This is a rejoinder to the fear-based model of the past,
recognizing greater complexity
 The existence of a dissociative subtype, combined with
the new affective criteria and the new arousal criterion of
self-destructive behavior, moves the description closer to
that of Complex Trauma
 Some of the research on PTSD may no longer apply
Implications of Changes to
PTSD Diagnosis in DSM 5
 Assessment instruments must change
 Different treatments may be needed for different
phenotypes of PTSD (anger, depression/guilt, anxiety,
 This may decrease the use of certain treatments,
particularly Prolonged Exposure, which is fear-based
Inside the Skin of PTSD
 Nerves on edge
 Jumpy
 Can’t sleep
 Nightmares
 Irritable all the time
 Explosive outbursts
 Wants to be left alone
 Depressed
 Can’t stand crowds
 Heart races/sweats
Inside the Skin of PTSD
 Hates New Year’s Eve and
July 4th
 Secretive
 Distrusts others
 Sees world as dangerous
 Constantly watching for
 Hates lines
 Overwhelmed by stimulation
 Feels responsible for trauma
Inside the Skin of PTSD
Copes by:
 Cutting off relationships
 Isolating
 Taking risks
 Self-harming behaviors
 Using drugs and alcohol
Faces of PTSD
Some Consequences of PTSD
 Damaged relationships
 Strain on families
 Domestic violence
 Multiple marriages
 Problems in parenting
 Children develop problems
More Consequences of PTSD
 Lost productivity
 Poverty
 Homelessness
 Legal problems
 Reduced quality of life
PTSD: A Case Example
Mr. V: Vietnam Veteran; many battles; career
Marine/Army man; married twice; automobile
accident; became agoraphobic; startles easily;
doesn’t trust others; nightmares; wife said she’s
leaving; dissociated and shot up the house; arrested
and jailed
PTSD: A Case Example
Mr. E: Army; guarded Tomb of the Unknown
Soldier; engaged; apartment broken into; tortured;
fiancée raped; fear of sleeping at night; triggered by
sports games; became hypersexual; seven children
by four women; became dependent on PCP; drove
while high, arrested, and jailed for nine months
PTSD: A Case Example
Mr. G: Gulf War Veteran; sent woman out on convoy
who was killed; significant guilt; isolated; began
drinking and using crack cocaine; arrested and
jailed; treated and stopped using crack; got
comfortable and started drinking again; dissociated
and arrested for drunk driving; jailed for a year
Resources for PTSD
 Handbook of PTSD by Matthew Friedman, Terence
Keane, and Patricia Resick
 Once a Warrior, Always a Warrior: Navigating the
Transition from Combat to Home--Including Combat
Stress, PTSD, and mTBI by Charles Hoge
 When Someone You Love Suffers from Posttraumatic Stress:
What to Expect and What You Can Do by Claudia Zayfert
and Jason Deviva
Resources for PTSD
 National Center for PTSD:
 International Society for Traumatic Stress Studies:
 International Society for the Study of Trauma and
 PTSD 101 courses:
Brian L. Meyer, Ph.D.
[email protected]