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

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 ScreeningII. Epidemiology and ComorbidityIII. Neurobiology and Treatment

Approaches

Outline of Presentation:

I. Diagnosis and ScreeningII. Epidemiology and ComorbidityIII. 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 SymptomsNightmares (or evidence thereof)FlashbacksIntrusive memoriesPhysiological reactivity with remindersCue-related distress

DSM-IV Post-traumatic Stress Disorder (PTSD)

At least 3 symptoms of avoidance, numbing and estrangement:

Avoidance of internal or external cuesEmotional estrangementEmotional numbing

DSM-IV Post-traumatic Stress Disorder (PTSD)

Avoidance symptoms, cont’d: Decreased interest in pleasurable or

usual activitiesPsychogenic amnesiaSense of a foreshortened future

DSM-IV Post-traumatic Stress Disorder (PTSD)

At least 2 symptoms of hyperarousal;Sleep disturbancesHyperstartleIrritability or anger outburstsHypervigilanceDecreased concentration

DSM-IV Post-traumatic Stress Disorder (PTSD)

Duration and Impairment Criteria:Occurring > 1 month post-traumaLasting > 1 monthInterfering with function

Subsyndromal PTSDAlso 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 ScaleStructured Clinical Interview for DSM-IV

(SCID) PTSD moduleStructured Interview for PTSD

Diagnostic Instruments

Self-administered questionnaires:Posttraumatic Diagnosis Scale

Coffey et al (1998): validation among detox patients

Impact of Event Scale-RevisedDavidson Traumatic Stress ScalePTSD Checklist

Outline of Presentation:

I. TerminologyII. Epidemiology and ComorbidityIII. Neurobiology and Treatment

Approaches

National Comorbidity SurveyPTSD prevalence: 5% males,10% femaleAmong 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 PTSD- vets smoked >25 cigs per day

Medical problems and PTSD

Higher rate of medical problems, including:

HTNChronic pain disordersHeart diseaseGI disorders

Medical problems and PTSD

Higher rate of HIV risk behaviorsKimmerling, 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 ScreeningII. Epidemiology and ComorbidityIII. 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 dysfunctionReduced 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 improvesThe substance use disorder may improve,

but does not go into remissionTreatment retention improvesMay 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 substance-induced psychiatric symptoms

Psychopharmacological Approaches

In PTSD, medications are part of an integrative strategy

As with psychotherapy, everything has been tried

Psychopharmacological Approaches

AntidepressantsRCT’s done in PTSD on:

SSRI’s (Fluoxetine, Paroxetine, Sertraline)SSNRI (Mirtazapine)TCA (Amitryptyline, Imipramine)MAOI (Phenelzine, brofaromine)

Psychopharmacological Approaches

Mood-stabilizing anticonvulsants (anti-glutaminergic): RCT on lamotrigine

Atypical antipsychoticsRCT’s on risperidone, quetiapine

Psychopharmacological Approaches

Anti-adrenergic agentsRCT on PrazosinClonidine 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 subjectsCurrent 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

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 substance-abuse 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 Approachesin PTSD with SUDs

How does one address the trauma?Discuss the trauma-related deficitsDiscuss the events of the traumaDiscuss the meaning of the traumaAll or some

Psychosocial Approachesin PTSD with SUDs

When does one address the trauma?NeverFirst LastThroughout

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 SafetyBack, 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 treatmentThroughout: weekly – twice

weekly urine toxicology screening

ARTSPhase 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 psychoeducationPTSD and addiction-related coping skills,

including relaxation training, anger management, assertiveness among others

Tacit motivational enhancement

ARTS

Phase II (weeks 13 and on):Stress InoculationProlonged 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 sessionsIndividual therapy Outpatients

Research-based Psychosocial Treatments for PTSD-SUDs

Najavits et al 1996: Seeking SafetyIntegrative method based on Judith

Herman’s work12-week, group therapy, 1.5 hours 2x/weekEmphasis on cognitive and coping skills

approachesNo 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-SUDSStructureGentle but firm limit-settingActive 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 TrialsTriffleman (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, homicidalAcutely manic, chronically psychotic

ARTS vs CBCST: Baseline characteristics

Demographics (N=36):Mean age: 44 + 8 years old56% female47% African-American, 35% Caucasian80% unemployed32% 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: OutcomesCAPS PTSD severity declined over time

(F=46.64, df=1,247, p<.0001)Declines vs baseline during follow-up

were 39-43% in both conditionsEffect 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 stimulant-positive 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 heroin-positive 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 riskPreventative 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 occurringOften associated with other disordersDifficult but feasible to treat with a

variety of methodologies