Comorbid Alcohol abuse or dependence and posttraumatic stress disorder

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                    Alcoholism and Posttraumatic Stress Disorder

                               Joe E. Thornton, M.D.
                          Alcohol Medical Scholars Program
                                    April 7, 2003

I. Introduction

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       A. This lecture is important because:

                  1. Alcoholism and Posttraumatic Stress Disorder (PTSD) are both
                  2. The symptoms from one can mimic the other
                  3. Co-occurring syndromes make each clinical picture more severe
                  4. Most physicians know little about either

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          The clinicianís dilemma is that people may increase their alcohol use
                       in response to trauma,
              Alcoholism can temporarily mimic PTSD
              Alcoholism makes preexisting disorders (including PTSD) worse

       Slide 4
       B. This lecture will cover :
               1. Clinical Information on Alcoholism
               2. Clinical Information on PTSD
               3. Strategies for diagnoses and treatment
               4. Strategies for primary care treatment interventions

II. Background ñ Alcohol

        A. Definitions

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               1. Alcohol use described as a spectrum (1)
                     Non problem use
                     At-risk use
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              2. Alcoholism refers to Alcohol Use Disorders (2)
              3. DSMIV Alcohol Use Disorders include both abuse and
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      4. Dependence: 3 + of
              a. Tolerance
              b. Withdrawal
              c. Larger amounts/ longer use
              d. Loss of control / unable to cut down on use
              e. Significant time spent on thinking or obtaining alcohol
              f. Reduced social functioning
              g. Continued use despite negative consequences

      Slide 8
      5. Alcohol Abuse: 1+ of
             a. Failure to fulfill major role obligations
             b. Physically hazardous use
             c. Legal problems related to use
             d. Interpersonal problems related to use

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B. Lifetime Prevalence (2)

       1. Abuse
            a. Men 12.5 %
            b. Women 6.4 %
      2. Dependence
            a. Men 20.1%
            b. Women 8.2 %

C. Clinical Course (3,4)

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       1. Following list is general picture; picture differs for any
       2. Early course and milestones similar to general population, e.g.:
               a. First drink ~ age 13
              b. First intoxication ~ age 16
              c. First problem ~ 21;
                       40% of all drinkers have some minor problem at
                        some time
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       3. Dependence ~age 28
              10% after age of 40, less than 10% before age 20
       4. Variable course
               a. Frequent periods of abstinence
                        Any given month ~50 % of alcoholics are abstinent
              b. Spontaneous remissions ~ 20%
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             5.Medical morbidity
                     Dependence cuts 15 years off the life span
                     Deaths from heart disease, cancer, accidents, suicide
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             6. Psychiatric symptoms are prominent
                     a. Almost 100% have insomnia and bad dreams
                     b. Major temporary syndromes such as depression occur
                             ~ 40%
                     c. Such symptoms occur in active alcoholism, disappear
                             with abstinence
                     d. Some alcohol related symptoms overlap with PTSD
                             symptoms, e.g. insomnia, bad dreams,
                                                  decreased participation in
             activities, abnormal affect,              irritability, difficulty

III. Background : PTSD (5,6)

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       Trauma Spectrum

       A. Definition

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             1. DSM-IV Posttraumatic stress disorder
              2. History of traumatic event
                     a. Person experienced, witnessed, or was confronted with a
                           disturbing event.
                     b. Response was intense fear, helplessness or        horror
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             3. Event re-experienced as 1 + of
                     a. Intrusive recall
                     b. Recurrent distressing dreams
                     c. Acting or feeling as if the event were recurring
                     d. Intense distress at cues of the events
                     e. Physiologic reactivity on exposure to cues
             4. Persistent avoidance of cues associated with the trauma and
                               numbing of responsiveness as indicated by 3 + of
                    a. Efforts to avoid thoughts related to events
                    b. Efforts to avoid cues of the trauma
                    c. Inability to recall important aspects
                    d. Diminished interest or participation in activities
                    e. Estrangement (alienated from family, friends)
                    f. Restricted range of affect
                    g. Foreshortened sense of future
             5. Increased arousal as evidenced by 2 +
            a. Difficulty falling asleep or staying asleep
            b. Irritability
            c. Difficulty concentrating
              d. Hypervigilance
              e. Exaggerated startle response
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       6. Duration of symptoms greater than 1 month
        7. Symptoms cause distress and impairment

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B. Lifetime prevalence (7,8)

       1. ~70% of persons in US exposed to 1+ trauma
       2. ~10% of trauma-exposed persons develop PTSD
       3. Lifetime prevalence of PTSD:
                 a. Men ñ 5%
               b. Women ñ 10%

 C. Clinical Course ( 9,10)

        1. Following list is general picture; picture differs for any individual
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       2. Risks for development of symptoms following trauma are
                                 associated with:
               Severity of trauma
               Prior Trauma
               Prior psychiatric history
               Peritraumatic dissociation (mentally separating from the
                   event when it occurs)
               Acute stress symptoms
               Autonomic hyperarousal (flushing, pupillary dilation, bowel
                   and bladder activity)
       Slide 20
       3. Variable course
                a. Generally follows Acute Stress Disorder
               b. Spontaneous remission is uncommon
       4. Physical symptoms (11)
               Common complaints include headache, gastrointestinal
                   complaints, chest pain, dizziness, other non-specific
                   somatic symptoms
               No definitive link with physical health or mortality
       5. Alcohol Use Disorders are common with PTSD (12)
               Alcohol use and intoxication increase emotional numbing,
                       social isolation, irritability
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IV. Epidemiology: Alcohol Dependence and PTSD Co-occur

       A. Patients with PTSD had lifetime rates of alcoholism 2-3x that of
                            community samples (7,10,12)

       B. Patients seeking treatment for alcoholism of PTSD 3x
                                 that of community samples

      C. Substance-dependent adolescents inpatients have 5x community rate
                    for PTSD (13, 14)

      D. Inpatient alcohol-dependent women have 5x of PTSD (15)

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V. However, PTSD and alcohol dependence symptoms overlap (15,16)

       A. Increased arousal seen during both alcohol withdrawal and PTSD

              1. Insomnia
              2. Nightmares
             3. Difficulty concentrating
              4. Irritability

       B. Symptoms of avoidance, emotional numbing, associated with PTSD,
             alcohol intoxication, or alcohol induced cognitive disorders

               1. Poor recall
               2. Difficulty concentrating
              3. Decreased interest or participation in activities
              4. Emotional blunting

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VI. Diagnostic strategies to see if PTSD is independent in an alcohol-
dependent person (2)

      A. Establish age of onset of alcohol dependence

      B. Establish periods of abstinence since onset of dependence

      C. Establish age of trauma and onset of PTSD

      D. See if PTSD existed before alcohol dependence or during 3+ months of

      E. Findings of dictate optimal treatment.
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VII. General treatment for alcohol use disorders (17,18)

       A. As with most chronic disorders, treatment is mostly
                                    cognitive/behavioral (19)

              1. Increase motivation for abstinence.
              2. Help rebuild life functioning.
              3. Relapse prevention.

       B. Intense treatment given for 2-4 weeks; then less intense for 6+ months

       C. Self-help groups can be important.

       D. Limited role for medications (20)

             1. Naltrexone, 50 -150mg/d, slightly better than placebo.
              2. Acamprosate, 2gm/d slightly better than placebo.
              3. Little support for disulfiram, 250mg/d
              4. No role for lithium, antidepressants, benzodiazepines (after
                        detoxification is done), antipsychotics, etc.

VIII. Treatment of PTSD

      A. Cognitive /behavioral therapies
            Slide 25
             1. Exposure Therapy (21)
                    a. Patient confronts the feared object or event with guided
                              help from therapist.
                    b. Patient educated about common reactions to trauma
                    c. Patient is trained in behavioral symptom management
                            e.g. breathing retraining
                    d. Patient exposed by a number of techniques to the
                              traumatic event and progressively masters the
                                              symptom response
            2. Stress Inoculation Training
                     a. Therapist helps the patient to learn to manage the s
                                       symptoms of anxiety
                     b. Review of traumatic event or thoughts of the event not
                     c. Effectiveness is greater than no treatment but may be
      less                   effective than Exposure Therapy

      B. Eye Movement Desensitization and Reprocessing (EMDR) (22)
              1. Wide use but still controversial, due to differences over the true
                      value of the eye movements as the key component of
                               2. Patient reviews trauma(s) with therapist
              3. Aversive experience evaluated
              4. Cognitive schemas (interpretation) re-evaulated
              5. Patient trained in lateral eye movements while focusing on
                      traumatic responses.

      C. Medications (23)
             1. SSRI Antidepressants, e.g. sertraline 100mg/d
             2. Other antidepressants, venlafaxine 225mg/d
             3. Anxiolytics, second line medication, clonazepam 2mg/d
                     Note: Short term use only, be aware of any concurrent
                             alcohol use, be aware of any history of substance
abuse or                                dependence, be aware of potential for
benzodiazepine                             abuse
             4. Mood stabilizers, second line medication, divalproex 1500mg/d
             5. Atypical antipsychotics, third line, olanzapine 10mg/d

IX. Treatment of Co-occurring PTSD and Alcohol Use Disorders

      Slide 26
      A. Wait and Treat Strategies (2).

              1. Achieve abstinence and monitor PTSD symptoms
              2. Control PTSD symptoms and monitor craving

      B. Sequential treatment

              1. Treat the most disabling syndrome first
              2. If second syndrome still present after time then treat

      Slide 27
      C. Comprehensive Treatment (24, 25)

             1. Coordinated treatments- alcohol counselors communicate with
                     therapists treating PTSD
              2. Integrated treatments- alcohol counselors and PTSD therapists
                               work as a team (26, 27)

Slide 28
X. Primary Care Treatment of Trauma and Alcoholism (28-31)

      A. Assessment
             1. Assess symptoms
             2. Assess in detail the patientís response to symptoms
                    a. Over the counter medication use
                    b. Alcohol or other substance use
             3. Psychosocial history
             4. Behavioral health history
             5. Trauma history (28, 29)

      B. Screening and brief intervention for AUD (32, 33)
             Slide 29
             1. Quantity frequency interview
                   a. How many days a week do you drink?
                    b.How much on typical drinking day?
                    c. What is the most you had had to drink on one day?
             2. Education about at-risk drinking
                     a. Men > 5 drink/d or 14 drinks /week
                     b. Women > 3 drinks/d or 7 drinks /week
             Slide 30
            3. Stage specific prevention messages
                     Alcohol risk level (abstinent, non-problem use, at-risk
                             use, abuse, dependence)

            Slide 31
            4. FERNSS
                   a. Feedback
                   b. Education
                   c. Recommendation
                   d. Negotiation
                   e. Secure agreement
                   f. Set follow-up

Slide 32
XI. Conclusion

      A. Alcohol Use Disorders and PTSD commonly co-occur

             1. Epidemiologic Data
             2. Clinical data

      B. Diagnosis of both disorders is essential for successful treatment

             1. Co-occurring disorders present with more severity and need
                     intensive treatment
             2. Untreated symptoms of one disorder may interfere with
                     compliance with treatment for other disorder

      C. Combined therapies have better outcomes
              1. Patients and providers may misinterpret isolated symptoms and
                        implement ineffective or detrimental interventions
              2. Combined and Integrated treatment approaches carefully
                             consider the relationships of symptoms and
      interactions with                  treatment interventions.

      D. All physicians have treatment opportunities
             1. Patients may misinterpret physical symptoms of anxiety and
                     seek care from primary care physicians or specialists
              2. The skilled physician may accurately diagnosis the physical
                      symptoms as related to alcohol or trauma or both
              3. The physician may utilized brief counseling techniques for
                              effective treatment.


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