Triple Trouble: Female, Addicted & What Else? Co- occurring Disorders in Women Cheryl A. Kennedy, M.D. Assoc. Prof. & Vice Chair Dept. Psychiatry New Jersey Medical School-UMDNJ Newark, New Jersey-October 2007

ADDICTION Addiction can be a primary disorder, but is often a result of Maladaptive coping with adverse events Self-medication for other, often psychiatric symptoms: pain, depression, anxiety, perceptual disturbance, paranoia High-risk recreational/experimental use Misuse, abuse of prescription drugs Poorly monitored prescribing practices

PTSD DSM IV CRITERIA* Characteristics of the Event –Involve actual or threatened death, serious injury, or other threat to one’s physical integrity –Witnessing an event that involves death, injury or a threat to the physical integrity of another person –Learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate *PTSD=post traumatic stress disorder DSM IV= Diagnostic & Statistical Manual 4th Ed

DSM IV CRITERIA Characteristics of the Immediate Response –The person’s response must involve intense fear, helplessness or horror –--Some controversy--What about those who react with NUMBNESS? –Individuals may have different abilities to recall or articulate intense emotional responses

REALITY OF TRAUMA Under appreciated Under diagnosed Under treated Leads to further long-term complications and co-morbid conditions (depression, substance use disorders, etc.) that confound Diagnosis

MYTHS We can define traumatic events through objective criteria alone Experiencing extreme events almost always leads to prolonged distress PTSD is the only important psychiatric response to traumatic events

TRAUMA QUESTIONNAIRE 1. Military/combat experience11. Diagnosed with a life-threatening personal illness 2. Raped12. Child of yours diagnosed with a life- threatening illness 3. Sexual assault other than rape13. Witnessed someone being killed or seriously injured 4. Held captive, tortured, 14. Unexpectedly discovering a dead or kidnapped body 5. Shot or stabbed15. Learned that a close friend/relative was raped or sexually assaulted 6. Mugged, held up, 16. Learned that a close friend/relative or threatened with a weaon was seriously physically attacked 7. Badly beaten up17. Learned that a close friend/relative was seriously injured in a motor vehicle accident 8. Serious car or motor vehicle 18. Learned that a close friend/relative crash was seriously injured in any other accident 9. Any other serious accident 19. Sudden, unexpected death of a close or injury friend or relative 10. Fire, flood, earthquake, 20. Heard gunshots in your neighborhood or other natural disaster

SYMPTOM CRITERIA DSM IV Intrusion: re-experiencing of the traumatic event; flashbacks; nightmares; unwanted thoughts of the event Avoidance: emotional numbing; feeling detached; avoidance of anything that reminds you of the trauma Arousal: difficulty sleeping; irritability; hyper-vigilance; exaggerated startle

Diagnostic Instruments Clinician administered scales PTSD scale Structured Clinical Interview for DSM-IV (SCID) Self-Report Scales PTSD Dx Scale (Coffey 1998) validated with detox patients Impact of Events Scale (Horowitz) Davidson Traumatic Stress Scale PTSD checklist, TRQ

Symptom List In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you… 1. Have had nightmares about it or thought about it when you did not want to? Y/N 2. Tried hard not to think about it; went out of your way to avoid situations that reminded you of it? Y/N 3. Were constantly on guard, watchful, or easily startled?Y/N 4. Felt numb or detached from others, activities, or your surroundings?Y/N

Other Traumas Chronic psychological, physical or sexual abuse. May be thought of as ‘low-level’ or considered part of the ‘norm.’ Life in the (violent) Big City in a dysfunctional family Living in a war zone Being a Refugee

‘Sub-Syndromal’ PTSD Also known as ‘ partial PTSD ’ No single, agreed upon definition, but most commonly: 2 of 3 symptom cluster criteria OR 1 intrusive-cluster symptom & meeting full criteria for another symptom cluster Stein et al, (1997) Am J Psychiatry 154(8):

Prevalence of Traumatic Events

Epidemiology of Events Lifetime prevalence of PTSD –30.9% for men and 26.9% for women Partial PTSD –22.5% of men and 21.2% of women ‘Current’ PTSD (NVVRS ) –15.2% for men and 8.1% for women

Course of PTSD PTSD can be a chronic psychiatric disorder that persists for decades –Classified as “chronic” if symptoms persist for 3 months or longer –course marked by remissions and relapses Delayed variant of PTSD –Precipitated by a situation that resembles the original trauma in a significant way (e.g., war veteran whose child is deployed; rape or incest survivor who is sexually harassed years later or daughter reaches same age).

Alcohol & Drug Abuse Alcohol abuse or dependence –Lifetime % –Current % Drug abuse or dependence –Lifetime - 5.7% –Current - 1.8%

Co-Morbidity If PTSD criteria are met, it is likely that criteria for one or more additional diagnoses will be met –major affective disorders, dysthymia, substance use disorders, anxiety disorders, or personality disorders. May be an artifact of our current decision- making rules for the PTSD diagnosis since there are not exclusionary criteria

Lifetime Prevalence of other Disorders by Hx PTSD Exposure PTSD Exposed Not Only Exposed (n=93) (n=301) (n=613) MDD36.6% 13.0% 10.1% Any Anxiety58.1% 26.3% 21.9% Alcohol A/D 31.2% 23.3% 19.1 Drug A/D 21.5% 13.3% 9.3% Data from epidemiologic study of young adults in southeast Michigan

Health Consequences Female veterans with PTSD are at higher risk of negative health consequences –Dermatologic: 3.9 x –Pain: 3.3 x –Gastrointestinal: 3.2 x –Ophthalmologic: 3.1 x –Endocrine: 3.1 x –Gynecologic: 2.4 x –Cardiovascular: 2.0 x

Impaired Quality of Life

Impaired Health Functioning

Neurobiology of PTSD Van der Kolk: Biological underpinnings of response to trauma are extremely complex Trauma--especially EARLY in the life cycle-- has long term effects on neuro-chemical responses to stress, including magnitude of the catecholamine response, duration & extent of cortisol response, serotonin and endogenous opioid system

Impact on an Individual’s Future Stressors on the nervous system can cause deficiency in or induce the following: Incapacity to modulate emotions Difficulty in learning new coping skills Alterations in immune competency Impairment in capacity to engage in meaningful social affiliation

Impact on the Developing Brain Children affected by trauma exhibit behaviors throughout the course of their subsequent lives that are owed to neuro-chemical and neuro-biological alterations and deficiencies brought about by the trauma(s).

WHO, WHAT, HOW WHO: Women who are younger Women who are minorities, Especially, African American WHAT: HIV infection HCV Infection How: Substance Abuse

High number of women who abuse drugs or alcohol have history of TRAUMA: Physical, sexual or otherwise Many women who have Post Traumatic Stress Disorder use substances as a coping medicine: maladaptive--can lead to Other health problems: HIV, HCV, etc.

You got What? Where? How? 44% of women with AIDS got HIV from Injection Drug Use [CDC 2003] Largely women of color, but no official data on how many HIV+ women have substance use disorders (SUD) regardless of mode of infection Most often, women are introduced to drugs by a sexual partner, in many cases the sexual abuser

The Stories Growing up in severe dysfunction Enduring multiple insults as children Alcohol, sexual and physical abuse highly prevalent in their families Drugs often come from the abuser Drugs as a way to cope with feelings of guilt, shame, inferiority

Rest of the Story Women who ran away as teens Found themselves on the street Frying pan to fire effect: Engaging in survival sex Relationships characterized by violence, alcohol or drug use HIV enters the scene

Significance Meta review of qualitative factors of effects of SUD in HIV+ women found significant effects— (shocking!) Most women had History of abuse Most were of reproductive age Either pregnant or mothers HIV infection follows abuse and use

SIGNIFICANCE Initially HIV experienced as life-threatening [? Why isn’t drug use considered dangerous? Why do people use?] Meta-review found that ultimately HIV was experienced as life-saving by many women Not so, motherhood—only a weak mediator

HOPE Providers must impart HOPE—therefore, you must have HOPE— Patients, like children from their parents, take their cues from the provider—HOPE While there is much work to be done, we know how to do it—main challenge is coordinating services in our health care ‘system’ Learn the ‘system’ and exploit it for your patients

Treatment Modalities For Chronic Mental Illness: Assertive Community Treatment Integrated Motivational Interviewing Cognitive Behavioral Therapy Family Intervention Multi-System Treatment

Significance of treating SA Women are an increasing proportion of HIV/AIDS cases. Due to treatments, HIV+ women living longer; Quality of Life = main focus. Black & Latina Women have reduced access to high-quality health care for HIV. Number of HIV+ Symptoms predict perceived Quality of Life

Alcoholism 2/3 Americans drink ETOH in a year 13.8 million develop health problems Younger starters at higher risk Can affect any organ MVAs, other accidents, injuries, DV Women often drink in secret

Alcoholism CONSEQUENCES Health care, Police, court, jail costs Unemployment, disability $100 Billion/year (NIAAA1997) Excess 100,000 deaths/year

Screen: CAGE At each visit ask about etoh use: How many drinks/week? Max drinks/occasion/past month? Have you ever tried to Cut down? Do you get Annoyed when people talk about your drinking? Do you feel Guilty about your drinking? Ever had an Eye-opener (1 st thing in am)?

Screen>>Intervene Screen and if: Greater than 14 drinks/wk or more than 4/occasion [men] Greater than 7 drinks/wk or more than 3/occasion [women] CAGE score >1>>Intervene

Intervene Assess for medical problems Labs: elevated GGTP, other LFTs, MCV, +BAL Behavioral/Functioning, family, work, school, accidents, legal problems

Motivation to Enter/ Sustain Treatment  Effective treatment need not be voluntary  Sanctions/enticements (family, employer, criminal justice system) can increase treatment entry/retention  Treatment outcomes are similar for those who enter treatment under legal pressure vs voluntary (length is import.)

Cover the Bases Harm Reduction Referral for Services Individual Support Public Health Measures

Effectiveness of Treatment  Drug treatment is disease prevention  Drug treatment reduces likelihood of HIV infection by 6 fold in injecting drug users  Drug treatment presents opportunities for screening, counseling, and referral

Effectiveness of Treatment  Goal of treatment is to return to productive functioning  Treatment reduced drug use by 40-60%  Treatment reduces crime by 40-60%  Treatment increases employment prospects by 40%  Drug treatment is as successful as treatment of diabetes, asthma, and hypertension

Self-Help and Drug Addiction Treatment  Complements and extends treatment efforts  Most commonly used models include 12-Step (AA, NA) and Smart Recovery  Most treatment programs encourage self-help participation during/after treatment

Cost-Effectiveness of Drug Treatment  Treatment is less expensive than not treating or incarceration (1 yr methadone maintenance = $4,700 vs. $18,400 for imprisonment)  Every $1 invested in treatment yields up to $7 in reduced crime-related costs  Savings can exceed costs by 12:1 when health care costs are included  Reduced interpersonal conflicts  Improved workplace productivity  Fewer drug-related accidents

REST OF STORY Meta-Review showed that getting HIV was prime motivator for many women to stop using drugs, especially if they had children Treatment involves treating RELAPSE WOMEN need specialized services… Integrated Case Management that includes housing, plan for kids (child care for appts; respite, etc.), vocational training to become employable to achieve economic independence

FINAL CHAPTER Women with HIV and SA probably also suffer with at least PTSD and usually Depression/Anxiety Must address the underlying issues in order to effectively treat SA (systems) Need service coordination, integration, mental health-informed, trauma-informed and culturally sensitive providers and programs