Lost in a Moment in Time: PTSD and Lost in a Moment in Time: PTSD and Substance Use Disorders Substance Use Disorders Herbert Street Clinic Detoxification Unit, RNSH Dr Glenys Dore. Robin Murray. April 2010
Dec 16, 2015
Lost in a Moment in Time: PTSD and Lost in a Moment in Time: PTSD and Substance Use DisordersSubstance Use Disorders
Herbert Street Clinic Detoxification Unit, RNSH
Dr Glenys Dore. Robin Murray. April 2010
PTSD (“TRAP”)
• Traumatic event:
• Re-experiencing or re-living the trauma
• Avoidance and Numbing
• Physical arousal/tension
PTSD: DSM-IV
EXPOSURE TO A TRAUMATIC EVENT in which both the following were present:
– the person experienced, witnessed or was confronted with an event/s that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
– the person’s response involved intense fear, helplessness or horror
Re-experiencing the trauma
– recurrent & intrusive recollections of the event, including images, thoughts or perceptions
– recurrent nightmares– acting or feeling as if the trauma were recurring
• dissociative flashbacks• sense of reliving the experience• illusions• hallucinations
Re-experiencing the trauma
With exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event:
– physiological reactivity – intense psychological distress
Avoidance and Numbing
Avoid reminders of trauma • thoughts, feeling, conversations• activities, places, people• unable to recall key aspects
Avoidance and Numbing
Emotional withdrawal: • reduced involvement in sig. activities • sense of detachment from others• restricted range of affect• sense of foreshortened future
Avoidance and Numbing
The patient is in survival mode – Avoidance: a way to keep away from
further danger which still feels present– The individual may feel safe but is
isolated and withdrawn from life
(Jan Ewing workshop June 2008)
Physical arousal/tension
– hypervigilant (“on guard”); – exaggerated startle response;– irritability & angry outbursts; – poor concentration;– difficulty falling or staying asleep
Physical arousal/tension
– Keeps the patient alert & prepared for the presence of danger
• know where the Exits are• sit with their back to the wall• need to be able to see and monitor everything
– “The threat detector” is so strong, the slightest “whiff” of a threat results in hyperarousal (Jan Ewing 2008)
PTSD Diagnosis (DSM-IV)
– Duration > one month– Associated with:
• significant distress or • impairment in functioning
Complex PTSD
• Genesis: CSA• PTSD symptoms +
– damage to attachment & self-systems– serious difficulties with affect regulation
& self-soothing– more likely to use dissociation as a
survival strategy + substance abuse
Dr Jan Ewing Oct 2008
Borderline Personality Disorder
Genesis:– Trauma may be important, or– Hypersensitive child + invalidating
environment
Dr Jan Ewing Oct 2008
• A (1) Abandonment • M (6) Mood instability (marked reactivity of mood)• S (5) Suicidal (or self-mutilating) behaviour • U (2) Unstable and intense relationships • I (4) Impulsivity (in two potentially self-damaging areas:
substance use; spending; sex; shoplifting; binge eating) • C (8) Control of anger• I (3) Identity disturbance • D (9) Dissociative (or paranoid) symptoms that are
transient and stress related• E (7) Emptiness (chronic feelings of)
Borderline personality disorder: A.M. SUICIDE (five criteria)Borderline personality disorder: A.M. SUICIDE (five criteria)
“Borderline individuals are the psychologicalequivalent of the 3rd-degree burn patient.They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering….”
Marsha Linehan 1993
What treatments work best?
Traditional SUD treatment
• Patients with and without PTSD improve substance use, mental & physical health
• PTSD group:– poorer physical & mental health– poorer occupational functioning– residual PTSD symptoms which
often trigger relapse– PTSD needs focussed treatment
Teesson & Mills Workshop 2006
NDARC
• Integrated treatment studies– PTSD & illicit drugs– PTSD & alcohol
Recruitment
Prevalence PTSD, depression, suicidality inpatients with SUD’s
• Dr Glenys Dore• Dr Katherine Mills• Robin Murray• Professor Maree Teesson• Philipa Farrugia• Anne-Marie Hall
Methodology
Screening Questionnaires:– all admissions over 9 month period– excluding readmissions
At admission or soon after:– Modified PsyCheck – suicidality– Zung Self-rating Depression Scale
• 20 items, self-report
Methodology
Trauma screening questionnaire– Trauma situations– 10 item screener
• based on most traumatic event• excluded grief/loss
Trauma situations
1. Seriously physically attacked or assaulted
2. Threatened with a weapon, held captive, kidnapped
3. Involved in life-threatening car accident
4. Involved in fire, flood, natural disaster
5. Witnessed someone badly injured or killed
6. Rape
7. Sexual molestation
8. Tortured or victim of terrorists
9. Direct combat in war situation
10. Person’s response involved intense fear, helplessness or horror
Trauma Screening Questionnaire (TSQ)
Please indicate (Yes/No) whether or not you have experienced any of the following at least twice in the past month:
25
1. Upsetting thoughts or memories about the event that have come into your mind against your will
2. Upsetting dreams about the event
3. Acting or feeling as thought the event were happening again
4. Feeling upset by reminders of the event
5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event
6. Difficulty falling or staying asleep
7. Irritability or outbursts of anger
8. Difficulty concentrating
9. Heightened awareness of potential dangers to yourself and others
10. Being jumpy or being startled at something unexpected
Results
• Total no. admissions = 304
• Completed data sets (all 3 Q’s)
= 253 (83.2%)
Sample characteristics
• 66.8% male• Mean age 37.29 (SD 10.54) years• Australian born 85.4%: ATSI 3.2%• 21% employed; 79% benefits• Main living situations:
– 24.9% alone; 23.3% parents– 6.7% homeless
Sample characteristics
Principal drug of concern:• alcohol 46.2%• opioids 26.1% • stimulants 9.5%• cannabis 9.1%, BZD 9.1%• 60.6% reported more than
one drug of concern• 34.6% IDU within last 3 months
Rates of trauma exposure
• Any type of trauma = 80.6%
(male 79.9%, female 82.1%)
• ANSMHWB = 57%
(male 64.5%, female 49.5%)
Creamer M et al. Psychol Med 2001
Rates of trauma exposure
• Mean no. of trauma types = 2.55• ANSMHWB: 55% 2 or more trauma
events
• Mean age first trauma = 14.12 years (similar males & females)
Creamer M et al. Psychol Med 2001
Rates of trauma exposure
Sex differences:• similar rates of exposure to any
trauma (male 79.9%, female 82.1%)• women 8.8 x more likely to have
been raped• women 4.67 x more likely to have
been sexually molested
Rates of trauma exposure
• Exposed to significantly more trauma types if:– polysubstance use– BZD main drug of concern
• Polysubstance use associated with– significantly younger age of 1st
trauma (12.49 vs 16.81 years)
Natural disaster
Trauma Situations
Trauma Situations
Sexual assault/rape
Frequency of trauma types
PTSD prevalence
Screened positive for current
PTSD = 44.9%
Lifetime history PTSD• 7.8% general pop’n (NCS):
–women 2x as likely as men: –(10.4% vs 5%)
• USA Vietnam vets: 28.9%
Trauma Situations!!!!
Screened positive for current
PTSD = 44.9%
Treatment seeking, with SUD’s:• 36 – 50% lifetime PTSD• 25 – 42% current PTSD• 41% ATOS
– Jacobsen LK, Am J Psych 2001
PTSD
Associated with• younger age of first trauma exposure• exposure to more trauma types• specific trauma types:
Odds Ratio
Raped 3.43
Witnessed serious injury or death 2.91
Natural disasters 2.57
Assaulted or attacked physically 2.45
PTSD
Not significantly associated with:• age• sex (Males 40.9%, Females 53%)• principal drug of concern• multiple drugs of concern
Depression & Suicidality
PTSD group significantly more likely to have:– moderate to severe depression– lifetime history self harm/suicide attempt/s
PTSD No PTSD Odds Ratio
Depression 33.3% 12.1% 3.6
Suicidality 48.6% 27.2% 2.4
Comorbidity
Comorbidity
50% with PTSD meet criteria for 3 or more other psychiatric diagnoses (NCS) commonly:– affective disorders (mainly
depression)– substance use disorders– other anxiety disorders
Brady KT et al. J Clin Psych 2000
Comorbidity
Patients may need treatment for multiple disorders including:– other anxiety disorders– major depressive disorder
Higher rates suicidality/self harm– suicide risk assessment &
management important Brady KT et al. J Clin Psych 2000
Trauma exposure & PTSD
Study groupHigh rates trauma exposure (81%)High rates current PTSD (45%) vs general
popn (8%)
PTSD associated with • greater trauma exposure• younger age 1st trauma• specific trauma types• moderate to severe depression• history of self-harm or attempted suicide
Relationship between SUD & PTSD
• Substance used to modify PTSD symptoms (“self medication”)
• As dependence develops, physiologic arousal from substance withdrawal exacerbates PTSD symptoms
• This exacerbation contributes to relapse• Substance using lifestyle: risk of
trauma exposure• Both disorders maintain/exacerbate the
other
Jacobson LK et al Am J Psych 2001 Mills K. Of Substance 2008
Recommendations
– Screen for PTSD, depression, suicidality– Remember avoidance part of disorder– If you don’t ask, they may not tell you– Normalise the patient’s response to the
trauma: validates their feelings & experience
– Awareness of triggers may facilitate best management eg male case manager
Ouimette et al 1998;
Mills et al 2009
Clinical implicationsfor patients in the unit?
PTSD symptoms often increase during withdrawal
– No longer masked by D & A use– Autonomic hyperactivity in withdrawal
exacerbates hyperarousal symptoms– Important to educate patients about
likely increase in symptoms– Provide tools/strategies to manage
symptoms
Strategies to manage PTSD symptoms
• Medication for anxiety
• Progressive muscle relaxation
• Breathing techniques
• Visualisation and imagery
• Grounding e.g. mindfulness
What about longer term treatment?
Treatment Phases
Establish therapeutic alliance/trust: – first step in any treatment– may take years– may be all you can do– may be impossible with some patients
where the patient’s transference is unmanageable
Dr Jan Ewing Oct 2008
Treatment Phases
Psychoeducation/normalisation
Symptomatic treatment – mood & affect management
- medication, - anger management- relaxation, grounding, CBT
Dr Jan Ewing Oct 2008
Treatment Phases
Behavioural desensitisation to reminders – CBT with graduated exposure
Imaginal exposure – trauma re-processing
- Imagery - EMDR
Dr Jan Ewing Oct
2008
Treatment PTSD & SUD– Gold standard PTSD: exposure– Traditionally considered inappropriate
with SUD: • fear >emotions trigger relapse• impaired cognitions SUD impair
ability for imaginal exposure• belief extended recovery needed
Teesson & Mills Workshop 2006
However….
Preliminary studies found integrated treatment• safe & effective• SUD and PTSD same time,
same therapist• Includes exposure therapy, CBT
Teesson & Mills Workshop 2006
Is exposure therapy for post traumatic stress disorder (PTSD)
efficacious among people with substance use disorders (SUD)?
Results from a randomised controlled trial
Katherine L Mills1, Maree Teesson1 , Emma Barrett1, Sabine Merz1, Julia
Rosenfeld1, Philippa Farrugia1, Claudia Sannibale1, Sally Hopwood2,
Amanda Baker3, Sudie Back4, Kathleen Brady4
1 National Drug and Alcohol Research Centre, University of New South Wales2 Traumatic Stress Clinic, Westmead Hospital
34 Centre for Brain and Mental Health Research, University of Newcastle4 Department of Psychiatry, Medial University of South Carolina
COPE v. IICOPE v. II
• NDARC conducted a randomised controlled trial of a modified version of CTPSD: Concurrent Treatment with Prolonged Exposure version II (COPE v2; Mills et al 2007).
• Target population: Individuals with any drug use disorder and multiple sources of trauma
• Sessions: 13 sessions with a clinical psychologist• Format: Individual• Program: CBT with imaginal and in vivo exposure
The first randomised controlled trial of exposure therapy among individuals with SUDs
COPE Treatment componentsCOPE Treatment components
• CBT for substance use (Sessions 1-4 and throughout)• Psychoeducation relating to both disorders and their
interaction (Sessions 1-4)• In vivo exposure (Sessions 5-12)• Imaginal exposure (Sessions 6-12)• Cognitive therapy for PTSD (Sessions 8-12)• Review, after care plan, termination (Session 13)
Both groups may receive treatment as usual for their substance use in the community (e.g., detox, residential rehabilitation, maintenance pharmacotherapies, counselling etc)
Randomised controlled trialRandomised controlled trial
Across the 9 mth follow-up period:
– Both groups evidenced improvements in their • Substance use• Severity of dependence• PTSD symptoms• Depression• Anxiety • General mental health
ConclusionConclusion
THEY DID NOT GET WORSE!
Participants randomised to COPE demonstrated:– significantly greater improvements in PTSD
symptoms – particularly avoidance and hyperarousal symptoms
These findings provide evidence in support of
treating PTSD among people with SUDs using COPE (Mills et al., 2007).
ConclusionConclusion
Questions for discussion
PTSD treatment really helps• How & where can we access it
for our patients?• Should all D & A workers be
trained in trauma counselling?• How best to support staff when
dealing with trauma issues?