1. Alcohol Medical Scholars Program @ 20031 ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER Joe E. Thornton, M.D.

2. Alcohol Medical Scholars Program @ 20032 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

3. Alcohol Medical Scholars Program @ 20033 Dilemma People may increase alcohol use in response to trauma Alcoholism could temporarily mimic PTSD Alcoholism makes preexisting disorders (including PTSD) worse

4. Alcohol Medical Scholars Program @ 20034 Lecture Overview Clinical information on alcoholism Clinical information on PTSD Strategies for diagnoses and treatment Strategies for primary care treatment interventions

5. Alcohol Medical Scholars Program @ 20035 ABST NON- PROB USE AT- RISK USE ABUSEDEP Use Consequences Repetition Loss of control, preoccupation, compulsivity, physical dependence ------ +--+-- + -/+ - ++++++ + ++ + Alcohol Use Spectrum

6. Alcohol Medical Scholars Program @ 20036 Alcoholism Definition Alcoholism = Alcohol Use Disorders DSM-IV Alcohol Use Disorders Alcohol dependence Alcohol abuse Alcoholism may be complicated by alcohol induced disorders

7. Alcohol Medical Scholars Program @ 20037 Alcohol Dependence In the past 12 months 3+ of: Tolerance Withdrawal More use Loss of control Significant time Giving up important activities Continued use

8. Alcohol Medical Scholars Program @ 20038 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

9. Alcohol Medical Scholars Program @ 20039 Alcoholism Prevalence Abuse Abuse Men 13 % Men 13 % Women 6 % Women 6 % Dependence Dependence Men 20 % Men 20 % Women 8 % Women 8 %

10. Alcohol Medical Scholars Program @ 200310 Clinical Course Early milestones similar to population First drink ~age 13 First drink ~age 13 First intoxication ~age 16 First intoxication ~age 16 First problem ~age 21 First problem ~age 21 40% of all drinkers have some minor problem at some time 40% of all drinkers have some minor problem at some time

11. Alcohol Medical Scholars Program @ 200311 Clinical Course Dependence ~age 28 Variable course Frequent periods of abstinence Any given month ~50% of alcoholics are abstinent Spontaneous remissions ~20%

12. Alcohol Medical Scholars Program @ 200312 Medical Morbidity Dependence cuts 15 years off the lifespan Deaths from Heart disease Cancer Accidents Suicide

13. Alcohol Medical Scholars Program @ 200313 Psychiatric Symptoms in Alcoholism Almost 100% have insomnia and bad dreams ~ 40% experience Depression Anxiety Psychosis Other alcohol induced disorders Symptoms resolve with abstinence

14. Alcohol Medical Scholars Program @ 200314 None Transient or no symptoms Acute Stress Disorder PTSD + Trauma Consequences Impairment > 30d Re-experience, arousal and avoidant symptoms Co-occurring syndromes ---- + -/+ - ++-++- ++++++++ + +++ ++ + Trauma Spectrum

15. Alcohol Medical Scholars Program @ 200315 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

16. Alcohol Medical Scholars Program @ 200316 PTSD Definition Re-experienced as 1+ symptoms Arousal as evidenced by 2+ symptoms Avoidance indicated by 3+ symptoms

17. Alcohol Medical Scholars Program @ 200317 PTSD Definition Duration >1 month Symptoms significant

18. Alcohol Medical Scholars Program @ 200318 PTSD Prevalence ~70% persons in US exposed to 1+ trauma ~11% of trauma-exposed persons develop PTSD Prevalence of PTSD: Men – 5% Women – 10%

19. Alcohol Medical Scholars Program @ 200319 Risks for PTSD Trauma severity Prior trauma Prior psychiatric history Peritraumatic dissociation Autonomic hyperarousal Acute stress symptoms

20. Alcohol Medical Scholars Program @ 200320 PTSD Clinical Course Onset follows Acute Stress Disorder Variable course Spontaneous remission uncommon Physical symptoms common No definitive link with physical health or mortality

21. Alcohol Medical Scholars Program @ 200321 PTSD and Alcoholism Community patients with PTSD have 2x alcoholism Community patients with PTSD have 2x alcoholism Patients seeking treatment for alcoholism have 3x PTSD Patients seeking treatment for alcoholism have 3x PTSD Substance dependence adolescent inpatients have 5x PTSD Substance dependence adolescent inpatients have 5x PTSD Inpatient alcohol rehabilitation adult women have 5x PTSD Inpatient alcohol rehabilitation adult women have 5x PTSD

22. Alcohol Medical Scholars Program @ 200322 Symptoms Insomnia Nightmares Irritability GI distress Tachycardia Dyspnea Tremor Fatigue Concentration impaired Poor recall Decreased interests Emotional blunting

23. Alcohol Medical Scholars Program @ 200323 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

24. Alcohol Medical Scholars Program @ 200324 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)

25. Alcohol Medical Scholars Program @ 200325 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

26. Alcohol Medical Scholars Program @ 200326 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

27. Alcohol Medical Scholars Program @ 200327 Alcoholism and PTSD Comprehensive Treatment Coordinated treatments Coordinated treatments Alcohol counselors communicate with therapists treating PTSD Alcohol counselors communicate with therapists treating PTSD Integrated treatments Integrated treatments Alcohol counselors and PTSD therapists work as a team Alcohol counselors and PTSD therapists work as a team

28. Alcohol Medical Scholars Program @ 200328 Treatment in Primary Care Assess symptoms Assess symptoms Assess in detail patient’s response to symptoms Assess in detail patient’s response to symptoms Over the counter medicines Over the counter medicines Alcohol or other substance use Alcohol or other substance use Psychosocial history Psychosocial history Behavioral health history Behavioral health history

29. Alcohol Medical Scholars Program @ 200329 Alcoholism Treatment in Primary Care Quantity /frequency interview Quantity /frequency interview How many days a week do you drink? How many days a week do you drink? How much on typical drinking day? How much on typical drinking day? What is the most you had had to drink on one day? What is the most you had had to drink on one day? Education about at-risk drinking Education about at-risk drinking Men > 5 drink/day or 14 drinks/week Men > 5 drink/day or 14 drinks/week Women > 3 drinks/day or 7 drinks/week Women > 3 drinks/day or 7 drinks/week

30. Alcohol Medical Scholars Program @ 200330 Brief Treatment Risk behavior education interventions Risk behavior education interventions Stage specific messages Stage specific messages Abstinent Abstinent Non-problem use Non-problem use At-risk use At-risk use Abuse, dependence Abuse, dependence

31. Alcohol Medical Scholars Program @ 200331 Counseling (FERNSS) Feedback Feedback Education Education Recommendation Recommendation Negotiation Negotiation Secure agreement Secure agreement Set follow-up Set follow-up

32. Alcohol Medical Scholars Program @ 200332 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