Course and treatment of patients with both substance use and posttraumatic stress disorders

doi:10.1016/S0306-4603(98)00064-1

Addictive Behaviors

Volume 23, Issue 6, November–December 1998, Pages 785-795

https://doi.org/10.1016/S0306-4603(98)00064-1 Get rights and content

Abstract

Posttraumatic stress disorder (PTSD) is a common co-occurring diagnosis in patients with substance use disorders (SUDs). Despite the documented prevalence of this particular “dual diagnosis,” relatively little is known about effective treatment for SUD-PTSD patients. This article reviews empirical research on the course and treatment of SUD-PTSD comorbidity and highlights clinically relevant findings. Based on this review, the following is noted: PTSD is highly prevalent in SUD patients, consistently associated with poorer SUD treatment outcomes, and related to distinct barriers to treatment. Specific treatment practices are recommended for substance abuse treatment providers: (a) All patients should be carefully screened and evaluated for trauma and PTSD; (b) referrals should be provided for concurrent treatment of SUD-PTSD, if available, or for psychological counseling with the recommendation that trauma/PTSD be addressed; and (c) increased intensity of SUD treatment should be offered in conjunction with referrals for family treatment and self-help group participation.

Section snippets

Posttraumatic stress disorder in substance abuse patients

PTSD is characterized by the development of a specific set of symptoms following exposure to a traumatic stressor (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV]; American Psychiatric Association, 1994). As defined by DSM-IV, traumatic stressors involve the direct experience, witnessing, or confronting of an event that includes actual or threatened death or serious injury, or other threat to the self/other’s physical integrity to which the person responds with intense

Longitudinal studies of the course of patients with sud-ptsd comorbidity

Only three studies have used prospective designs and repeated assessments to examine substance abuse treatment outcomes in SUD-PTSD patients. Brown et al. (1996) compared substance-dependent women with and without a comorbid diagnosis of PTSD on their alcohol and drug use 3 months after inpatient substance abuse treatment. Strengths of this study include the use of structured clinical interviews to diagnose PTSD and SUDs, and the assessment of daily substance use with the Time-Line Follow-Back

Treatment of comorbid sud-ptsd

Most clinical researchers now emphasize the need for concurrent treatment of both substance use problems and PTSD symptoms (e.g., Abueg and Fairbank 1992, Najavits, Weiss, & Liese 1996, Stine & Kosten 1995).1

Acknowledgements

The first author is supported by the Department of Veterans Affairs Mental Health Strategic Health Group and the Health Services Research and Development Service.

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Dans le cadre de l’examen psychiatrique des dommages d’une victime, la recherche d’un lien d’imputabilité entre un événement, un syndrome post-traumatique et des symptômes d’addiction est particulièrement difficile. Nous tentons de clarifier les problèmes liés au raisonnement médico-légal en psychiatrie.
Nous effectuons une revue de la littérature sur deux points. Le premier concerne les notions d’imputabilité, de causalité médicale et de causalité juridique. Le deuxième porte sur les liens entre des conduites addictives et des symptômes traumatiques. Via PubMed et Ascodocpsy, avec les mots clefs suivants : « Substance use disorder in patient with post-traumatic stress disorder ». Dans le champ psychodynamique avec la notion de « traumatophilie ».
1/Le raisonnement juridique rentre dans une démarche rétrospective et recherche l’attribution sociale d’une responsabilité pénale, civile ou administrative. Il est en contradiction avec le raisonnement médical qui vise un projet de soins tourné vers l’action, l’avenir et une possible guérison. 2/Les critères d’imputabilité sont issus d’une médecine d’organe et sont marqués par un modèle lésionnel d’organe. Ils ne sont pas pertinents pour la psychiatrie. 3/Les liens entre le traumatisme et l’addiction sont complexes car il existe une influence réciproque entre l’addiction et l’état de stress post-traumatique : la persistance de l’un favorise la rechute ou l’aggravation de l’autre. Sur un plan statistique, les études montrent une association franche entre des troubles addictifs et des troubles psycho-traumatiques. Les patients qui présentent une comorbidité ESPT/addiction ont par rapport à un ESPT isolé, une évolution plus péjorative surtout si cette comorbidité est associée à des antécédents d’abus durant l’enfance, des maltraitances, une pathologie antérieure, la prise de cocaïne et d’opiacés, un faible soutien par les proches. Quatre modèles psychopathologiques font références : le modèle de risque élevé de trauma, le modèle de vulnérabilité partagée, le modèle de susceptibilité, le modèle de l’automédication. Sur un plan psychodynamique, l’addiction peut se modéliser comme une tentative d’anesthésie psychique, de contrôle et de liaison des angoisses traumatiques.
Pour clarifier le raisonnement médico-légal en psychiatrie portant sur l’imputabilité d’un événement sur des symptômes psycho-traumatiques et des symptômes addictifs, nous proposons d’assumer les spécificités de la maladie mentale. Les maladies mentales sont des maladies fonctionnelles. Il faut donc chercher des modalités de liaison, et non de lésion, entre différents facteurs psychiques. L’addiction est à envisager systématiquement comme un facteur comorbide d’un syndrome psychotraumatique. Entre une addiction et un ESPT : la persistance de l’un favorise la rechute ou l’aggravation de l’autre. Le lien d’imputabilité nous apparaît intéressant à explorer selon les hypothèses développées dans les modèles de comorbidité somatoformes ou bipolaires. Nous proposons plusieurs questions-types qui peuvent aider à la poursuite d’un raisonnement clinique autour de l’imputabilité des troubles.
In the context of the psychiatric examination of the damage of a victim, the research for a link of imputability between an event, a post-traumatic syndrome and symptoms of addiction is specially difficult. We attempt to clarify issues related to forensic thinking in psychiatry.
We carry out a review of the literature on two points: The first one concerns the notions of imputability, medical causality and legal causality. The second one concerns the links between addictive behaviors and traumatic symptoms. Via PubMed and Ascodocpsy, with the following keywords: “Substance use disorder in patient with post-traumatic stress disorder”. In the psychodynamic field with the notion of “traumatophilia”.
1/The legal reasoning is part of a retrospective approach and seeks the social assignment of criminal, civil or administrative responsibility. It contradicts the medical reasoning which aims for a care project focused on action, the future and a possible cure. 2/Imputability criteria come from organ medicine and are marked by an organ lesion model. They are irrelevant to psychiatry. 3/The links between trauma and addiction are complex because there is a reciprocal influence between addiction and post-traumatic stress disorder: the persistence of one promotes the relapse or worsening of the other one. On a statistical level, the studies show a clear link between addictive disorders and psycho-traumatic disorders. Patients with PTSD/addiction comorbidity have, compared to isolated PTSD, a more pejorative evolution, especially if PTSD/addiction is associated with a history of childhood abuse, mistreatment, previous pathology, cocaine use and drug abuse opiates, low support by relatives. Four psychopathological models are referred to PTSD/addiction: the high risk of trauma model, the shared vulnerability model, the susceptibility model, the self-medication model. On a psychodynamic level, addiction can be modeled as an attempt at psychic anesthesia, control and binding of traumatic anxieties. On the neurobiological level, the reference models are based on the hypothalamic-pituitary and noradrenergic system, the opioid systems, NMDA and GABA.
To clarify the medico-legal reasoning in psychiatry relating to the imputability of an event on psycho-traumatic symptoms and addictive symptoms, we propose to assume the specificities of mental illness. Mental illnesses are functional illnesses. It is therefore necessary to look for modalities of connection, and not of lesion, between different psychic factors. Addiction should be systematically considered as a comorbid factor of a psychotraumatic syndrome. Between an addiction and PTSD: the persistence of one favors the relapse or worsening of the other. The imputability link seems interesting to us to explore according to the hypotheses developed in the somatoform or bipolar comorbidity models. We suggest several standard questions that may help in the pursuit of clinical reasoning around the imputability of disorders. Is the traumatic disorder primary and the addiction sequel? Is addictive behavior primary and after effects disorders? Are the two disorders primary and independent? Are the two disorders the outcome of the same underlying cause? Is the traumatic disorder altered by the addiction? Are the traumatic disorder and the addictive disorder combined to form a neopathology? Is addiction a symptom of traumatic disorder? Does the addiction bring out the traumatic disorder? Is the addiction an attempt to self-medicate for the traumatic disorder? Do addiction and traumatic disorder share common risk factors? Circular causality model: are addiction and traumatic disorder mutually reinforcing?
Practical Considerations for Treating Comorbid Posttraumatic Stress Disorder in the Addictions Clinic: Approaches to Clinical Care, Leadership, and Alleviating Shame
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Posttraumatic stress disorder (PTSD) symptoms have been shown to increase the likelihood of substance use in the general population. First responders (e.g., EMTs, paramedics, and firefighters) are routinely exposed to potentially traumatic events (PTEs) as part of their regular duties, increasing their risk for a range of adverse mental health outcomes including PTSD symptoms. However, no study to our knowledge has explored the relationship between PTEs, PTSD symptoms, and substance use in this population. In the current study, we examined whether PTSD symptoms were associated with alcohol and drug use in first responders above and beyond demographic variables, job-related characteristics, social support, and cumulative work-related PTE exposure, and whether work-related PTE exposure had an indirect effect on substance use via PTSD symptoms.
Participants (N = 885; mean age = 37.13; 59.0% male; 91.5% White) were recruited from all 50 U.S. states, the Virgin Islands, and Puerto Rico to complete an online survey.
In hierarchical regression analyses, PTSD symptoms were significantly associated with alcohol and drug use above and beyond all the other variables. Work-related PTE exposure was not a significant predictor of either outcome once PTSD symptoms were included, suggesting that PTEs confer risk for substance use via their association with PTSD symptoms. This finding was confirmed by an analysis showing that PTE exposure had a significant indirect effect on both alcohol and drug use via PTSD symptoms.
Results support the need for periodic assessment of both PTSD symptoms and substance use in first responders.
Stress-induced vulnerability to develop cocaine addiction depends on cofilin modulation
2021, Neurobiology of Stress
Actin dynamics in dendritic spines can be associated with the neurobiological mechanisms supporting the comorbidity between stress exposure and cocaine increase rewards. The actin cytoskeleton remodeling in the nucleus accumbens (NA) has been implicated in the expression of stress-induced cross-sensitization with cocaine. The present study evaluates the involvement of cofilin, a direct regulator of actin dynamics, in the impact of stress on vulnerability to cocaine addiction. We assess whether the neurobiological mechanisms that modulate repeated-cocaine administration also occur in a chronic restraint stress-induced cocaine self-administration model. We also determine if chronic stress induces alterations in dendritic spines through dysregulation of cofilin activity in the NA core. Here, we show that the inhibition of cofilin expression in the NA core using viral short-hairpin RNA is sufficient to prevent the cocaine sensitization induced by chronic stress. The reduced cofilin levels also impede a-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor surface expression enhancement and promote the reduction of head diameter in animals pre-exposed to stress after a cocaine challenge in the NA core. Moreover, downregulation of cofilin expression prevents facilitation of the acquisition of cocaine self-administration (SA) in male rats pre-exposed to chronic stress without modifying performance in sucrose SA. These findings reveal a novel, crucial role for cofilin in the neurobiological mechanisms underpinning the comorbidity between stress exposure and addiction-related disorders.
Longitudinal assessment of PTSD and illicit drug use among male and female OEF-OIF veterans
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Posttraumatic stress disorder (PTSD) and substance use share both directional (“self-medication”) and mutually-reinforcing associations over time. Research on gender differences regarding the co-occurrence of PTSD and substance use over time remains limited and largely focused on alcohol use; less is known regarding the co-occurrence of PTSD and illicit drug use, especially among veteran men vs. women. As the proportion of women in the military expands, we believe a greater focus on gender differences is warranted.
We conducted a cross-lagged panel analysis of PTSD symptoms and drug use problems using two waves of data from a large, nationwide longitudinal registry of post-9/11 veterans. Participants included 608 men and 635 women (N = 1243; M_age = 42.3; 75.2% White) who completed self-report PTSD and drug use problem questionnaires at T1 and again at T2 15–37 months later.
Veteran men reported more severe drug use and related problems overall, yet the cross-sectional correlation between PTSD and drug use problems was strongest among drug using veteran women. In our cross-lagged models, we found that PTSD symptoms predicted future drug use problems among veteran men, whereas drug use problems predicted future PTSD symptom severity among women.
These results support the self-medication pathway among veteran men but not women, for whom drug use problems might prolong or exacerbate PTSD symptom severity over time. These results are consistent with some emerging evidence but also provide novel insight into functional associations governing the longitudinal course of PTSD and drug use problems for men vs. women.
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Substance use disorder (SUD) and posttraumatic stress disorder (PTSD) are highly comorbid. Self-medication hypothesis (SMH) is a seminal theory aiming to account for the relationship between these disorders. The current study examined hypotheses based on SMH in SUD patients during the very first days of detoxification. Based on SMH we expected a positive association between PTSD and craving concurrently as well as on each following day.
A time series with 108 SUD patients used daily self-report questionnaires assessing PTSD symptom severity (PCL-5) and craving (MaCs) for six consecutive days. Daily associations between PTSD symptom severity and craving on the same and on the following day during the first week of detoxification were estimated using linear mixed models.
There was a significant decrease in PTSD symptom severity during detoxification (ß = -2.06, p < 0.001). Further, PTSD symptom severity predicted craving on the same day (ß = 0.36, p < 0.001) but did not predict craving on the next day (ß = -0.01, p = 0.82).
Results of the current study only partially support assumptions based on SMH, and points towards a more complex and reciprocal relationship between PTSD and SUD.

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^☆: John W. Finney, Rachel Kimerling, Franz Moggi, and Rudolph H. Moos provided comments on this article.

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Course and treatment of patients with both substance use and posttraumatic stress disorders☆

Abstract

Section snippets

Posttraumatic stress disorder in substance abuse patients

Longitudinal studies of the course of patients with sud-ptsd comorbidity

Treatment of comorbid sud-ptsd

Acknowledgements

Addictive Behaviors

Drug and Alcohol Dependence

Journal of Substance Abuse Treatment

Journal of Substance Abuse Treatment

Journal of Substance Abuse

Journal of Substance Abuse Treatment

Addictive Behaviors

Behaviour Research and Therapy

Behavioral treatment of posttraumatic stress disorder and co-occurring substance abuse

Diagnostic and statistical manual of mental disorders

Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence

Journal of Clinical Psychiatry

Chronic PTSD in Vietnam combat veteransCourse of illness and substance abuse

American Journal of Psychiatry

Substance use disorder-PTSD comorbidityPatient’s perceptions of symptom interplay and treatment issues

Journal of Substance Abuse Treatment

Post-traumatic stress disorder and substance abuse relapse among womenA pilot study

Psychology of Addictive Behaviors

Posttraumatic stress disorder and substance abuseUse of research in a clinical setting

Journal of Traumatic Stress

Treating addicted survivors of trauma

Patterns of appraisal and coping across different stressor conditions among former prisoners of war with and without posttraumatic stress disorder

Journal of Consulting and Clinical Psychology