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Lost in a Moment in Time: PTSD and Substance Use Disorders Herbert Street Clinic Detoxification Unit, RNSH Dr Glenys Dore. Robin Murray. April 2010.

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Presentation on theme: "Lost in a Moment in Time: PTSD and Substance Use Disorders Herbert Street Clinic Detoxification Unit, RNSH Dr Glenys Dore. Robin Murray. April 2010."— Presentation transcript:

1 Lost in a Moment in Time: PTSD and Substance Use Disorders Herbert Street Clinic Detoxification Unit, RNSH Dr Glenys Dore. Robin Murray. April 2010


3 PTSD (“TRAP”) Traumatic event: Re-experiencing or re-living the trauma Avoidance and Numbing Physical arousal/tension

4 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

5 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

6 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

7 Avoidance and Numbing Avoid reminders of trauma thoughts, feeling, conversations activities, places, people unable to recall key aspects

8 Avoidance and Numbing Emotional withdrawal: reduced involvement in sig. activities sense of detachment from others restricted range of affect sense of foreshortened future

9 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a way to keep away from further danger which still feels present –The individual may feel safe but is isolated and withdrawn from life (Jan Ewing workshop June 2008)

10 Physical arousal/tension –hypervigilant (“on guard”); –exaggerated startle response; –irritability & angry outbursts; –poor concentration; –difficulty falling or staying asleep

11 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)

12 PTSD Diagnosis (DSM-IV) –Duration > one month –Associated with: significant distress or impairment in functioning

13 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

14 Borderline Personality Disorder Genesis: –Trauma may be important, or –Hypersensitive child + invalidating environment Dr Jan Ewing Oct 2008


16 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)

17 “ Borderline individuals are the psychological equivalent 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

18 What treatments work best?

19 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

20 NDARC Integrated treatment studies –PTSD & illicit drugs –PTSD & alcohol Recruitment

21 Prevalence PTSD, depression, suicidality inpatients with SUD’s Dr Glenys Dore Dr Katherine Mills Robin Murray Professor Maree Teesson Philipa Farrugia Anne-Marie Hall

22 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

23 Methodology Trauma screening questionnaire –Trauma situations –10 item screener based on most traumatic event excluded grief/loss

24 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

25 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

26 Results Total no. admissions = 304 Completed data sets (all 3 Q’s) = 253 (83.2%)

27 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

28 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

29 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

30 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

31 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

32 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 1 st trauma (12.49 vs 16.81 years)

33 Natural disaster

34 Trauma Situations


36 Sexual assault/rape

37 Frequency of trauma types

38 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%

39 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

40 PTSD Associated with younger age of first trauma exposure exposure to more trauma types specific trauma types: Odds Ratio Raped3.43 Witnessed serious injury or death2.91 Natural disasters2.57 Assaulted or attacked physically2.45

41 PTSD Not significantly associated with: age sex (Males 40.9%, Females 53%) principal drug of concern multiple drugs of concern

42 Depression & Suicidality PTSD group significantly more likely to have: – moderate to severe depression – lifetime history self harm/suicide attempt/s PTSDNo PTSDOdds Ratio Depression 33.3%12.1%3.6 Suicidality 48.6%27.2%2.4

43 Comorbidity

44 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

45 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

46 Trauma exposure & PTSD Study group High rates trauma exposure (81%) High rates current PTSD (45%) vs general popn (8%) PTSD associated with greater trauma exposure younger age 1 st trauma specific trauma types moderate to severe depression history of self-harm or attempted suicide


48 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

49 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

50 Clinical implications for patients in the unit?

51 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

52 Strategies to manage PTSD symptoms Medication for anxiety Progressive muscle relaxation Breathing techniques Visualisation and imagery Grounding e.g. mindfulness

53 What about longer term treatment?

54 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

55 Treatment Phases Psychoeducation/normalisation Symptomatic treatment – mood & affect management - medication, - anger management - relaxation, grounding, CBT Dr Jan Ewing Oct 2008

56 Treatment Phases Behavioural desensitisation to reminders – CBT with graduated exposure Imaginal exposure – trauma re-processing - Imagery - EMDR Dr Jan Ewing Oct 2008

57 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

58 However…. Preliminary studies found integrated treatment safe & effective SUD and PTSD same time, same therapist Includes exposure therapy, CBT Teesson & Mills Workshop 2006

59 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 Mills 1, Maree Teesson 1, Emma Barrett 1, Sabine Merz 1, Julia Rosenfeld 1, Philippa Farrugia 1, Claudia Sannibale 1, Sally Hopwood 2, Amanda Baker 3, Sudie Back 4, Kathleen Brady 4 1 National Drug and Alcohol Research Centre, University of New South Wales 2 Traumatic Stress Clinic, Westmead Hospital 34 Centre for Brain and Mental Health Research, University of Newcastle 4 Department of Psychiatry, Medial University of South Carolina

60 COPE 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

61 COPE 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)

62 N = 103 55 Treatment (53%) (receive COPE) 48 Control (47%) (assessment only) 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 trial

63 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 Conclusion THEY DID NOT GET WORSE!

64 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). Conclusion


66 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?


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