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

2. Outline of Presentation:
I. Diagnosis and Screening
II. Epidemiology and Comorbidity
III. Neurobiology and Treatment Approaches

3. Outline of Presentation:
I. Diagnosis and Screening
II. Epidemiology and Comorbidity
III. Treatment Approaches

4. 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….

5. 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.

6. DSM-IV Post-traumatic Stress Disorder (PTSD)
At least 1 re-experiencing symptom:
“Classic” PTSD Symptoms
Nightmares (or evidence thereof)
Flashbacks
Intrusive memories
Physiological reactivity with reminders
Cue-related distress

7. DSM-IV Post-traumatic Stress Disorder (PTSD)
At least 3 symptoms of avoidance, numbing and estrangement:
Avoidance of internal or external cues
Emotional estrangement
Emotional numbing

8. DSM-IV Post-traumatic Stress Disorder (PTSD)
Avoidance symptoms, cont’d:
Decreased interest in pleasurable or usual activities
Psychogenic amnesia
Sense of a foreshortened future

9. DSM-IV Post-traumatic Stress Disorder (PTSD)
At least 2 symptoms of hyperarousal;
Sleep disturbances
Hyperstartle
Irritability or anger outbursts
Hypervigilance
Decreased concentration

10. DSM-IV Post-traumatic Stress Disorder (PTSD)
Duration and Impairment Criteria:
Occurring > 1 month post-trauma
Lasting > 1 month
Interfering with function

11. Subsyndromal PTSD Also 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):

12. Diagnostic Instruments
Interviews:
Clinician Administered PTSD Scale
Structured Clinical Interview for DSM-IV (SCID) PTSD module
Structured Interview for PTSD

13. Diagnostic Instruments
Self-administered questionnaires:
Posttraumatic Diagnosis Scale
Coffey et al (1998): validation among detox patients
Impact of Event Scale-Revised
Davidson Traumatic Stress Scale
PTSD Checklist

14. Outline of Presentation:
I. Terminology
II. Epidemiology and Comorbidity
III. Neurobiology and Treatment Approaches

15. National Comorbidity Survey
PTSD prevalence: 5% males,10% female
Among 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:

16. 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)

17. 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

18. Medical problems and PTSD
Higher rate of medical problems, including:
HTN
Chronic pain disorders
Heart disease
GI disorders

19. Medical problems and PTSD
Higher rate of HIV risk behaviors
Kimmerling, et al (1998): Higher than expected rates of PTSD among HIV+ women
Higher rate of mortality

20. 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

21. Outline of Presentation:
I. Diagnosis and Screening
II. Epidemiology and Comorbidity
III. Neurobiology and Treatment Approaches

22. Neurobiology of PTSD
Increased catecholamines, decreased alpha-2 adrenergic receptors
HPA disturbances: decreased glutocorticoid levels, increased glutocorticoid receptors
Increased central corticotropin-releasing factor

23. Neurobiology of PTSD Serotonergic dysfunction
Reduced beta-endorphin levels and increased pain thresholds

24. Brain Activation Changes in PTSD
Hendler et al (2003) NeuroImage, 19:

25. Psychopharmacological Approaches to PTSD

26. Psychopharmacotherapy for the Dually Diagnosed
Treating the nonsubstance Axis I disorder:
The nonsubstance Axis I disorder improves
The substance use disorder may improve, but does not go into remission
Treatment retention improves
May have a durable effect, even after discontinuation

27. 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

28. Psychopharmacological Approaches
In PTSD, medications are part of an integrative strategy
As with psychotherapy, everything has been tried

29. Psychopharmacological Approaches
Antidepressants
RCT’s done in PTSD on:
SSRI’s (Fluoxetine, Paroxetine, Sertraline)
SSNRI (Mirtazapine)
TCA (Amitryptyline, Imipramine)
MAOI (Phenelzine, brofaromine)

30. Psychopharmacological Approaches
Mood-stabilizing anticonvulsants (anti-glutaminergic):
RCT on lamotrigine
Atypical antipsychotics
RCT’s on risperidone, quetiapine

31. Psychopharmacological Approaches
Anti-adrenergic agents
RCT on Prazosin
Clonidine used frequently in children

32. Psychopharmacological Approaches
Benzodiazepines:
1 RCT: Alprazolam vs placebo, 3.75 mg qD: no effect on core PTSD symptoms

33. 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

34. Pharmacotherapy for PTSD-SUDs:
A case series regarding sertraline (Zoloft):
N=9 civilian male and female subjects
Current 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:

35. Psychosocial Treatment

37. 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

38. 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:

39. 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:

40. Psychosocial Approaches in PTSD with SUDs
How does one address the trauma?
Discuss the trauma-related deficits
Discuss the events of the trauma
Discuss the meaning of the trauma
All or some

41. Psychosocial Approaches in PTSD with SUDs
When does one address the trauma?
Never
First
Last
Throughout

42. 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:

43. 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 Safety
Back, Brady et al: Concurrent Treatment of PTSD and Cocaine Dependence

44. 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

45. Assisted Recovery from Trauma and Substances
Phased, sequential treatment
Throughout: weekly – twice weekly urine toxicology screening

46. ARTS
Phase 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 psychoeducation
PTSD and addiction-related coping skills, including relaxation training, anger management, assertiveness among others
Tacit motivational enhancement

47. ARTS Phase II (weeks 13 and on): Stress Inoculation
Prolonged 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.

48. 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.

49. ARTS 5 months duration Twice-weekly hour-long sessions
Individual therapy
Outpatients

50. Research-based Psychosocial Treatments for PTSD-SUDs
Najavits et al 1996: Seeking Safety
Integrative method based on Judith Herman’s work
12-week, group therapy, 1.5 hours 2x/week
Emphasis on cognitive and coping skills approaches
No direct discussion of the specifics of traumatic events

51. 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

53. Commonalities among Psychosocial approaches to PTSD-SUDS
Structure
Gentle but firm limit-setting
Active monitoring of substance use, PTSD symptoms, associated other problems
Maintaining the focus, not just crisis management

54. Commonalities among Psychosocial approaches to PTSD-SUDS
On-going, regularly scheduled supervision
Videotaped therapy sessions

55. Research Trials
Triffleman (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)

56. 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

57. 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

58. ARTS vs CBCST: Major Exclusion Criteria
Unable/unwilling/contraindicated to discontinue current other psychosocial treatment
Imminently suicidal, homicidal
Acutely manic, chronically psychotic

59. ARTS vs CBCST: Baseline characteristics
Demographics (N=36):
Mean age: years old
56% female
47% African-American, 35% Caucasian
80% unemployed
32% on probation or parole

60. ARTS vs CBCST: Baseline characteristics
83% designated heroin as major problem substance on the ASI
Mean: lifetime substance dependence disorders

61. ARTS vs CBCST: Baseline characteristics
Index traumas: Traumatic bereavement (16), Interpersonal victimization (11), Witnessed interpersonal victimization (6), Other (3)
Mean baseline CAPS severity: ; 78% had full current PTSD

62. ARTS vs CBCST: Outcomes
ARTS subjects attended more sessions (mean: ) than CBCST subjects (mean= ; Log-rank 7.83, p<.005)
Including more sessions during the PTSD-focused phase ( sessions) than CBCST ( ; Breslow=6.31, p=.01)

64. ARTS vs CBCST: Outcomes
CAPS PTSD severity declined over time (F=46.64, df=1,247, p<.0001)
Declines vs baseline during follow-up were 39-43% in both conditions
Effect sizes from 1.25 – 1.61; ARTS ES at 18 month follow-up was 2.25.

65. ARTS vs CBT

66. 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.

68. 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)

69. 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)

70. 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

71. 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

72. 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

73. Vicarious Traumatization
Can occur in anyone with sufficient exposure
Those with less training are more at risk
Preventative strategies:
Talk, talk, talk: get supervision, talk with a work-buddy, talk with religious/spiritual leader or peers, friends, etc.
Good Self-care habits

74. Conclusions PTSD-SUD is: Commonly occurring
Often associated with other disorders
Difficult but feasible to treat with a variety of methodologies