Lost in a Moment in Time: PTSD and Lost in a Moment in Time: PTSD and Substance Use DisordersSubstance Use Disorders

Herbert Street Clinic Detoxification Unit, RNSH

Dr Glenys Dore. Robin Murray. April 2010

PTSD (“TRAP”)

• Traumatic event:

• Re-experiencing or re-living the trauma

• Avoidance and Numbing

• Physical arousal/tension

PTSD: DSM-IV

EXPOSURE TO A TRAUMATIC EVENT in which both the following were present:

– the person experienced, witnessed or was confronted with an event/s that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

– the person’s response involved intense fear, helplessness or horror

Re-experiencing the trauma

– recurrent & intrusive recollections of the event, including images, thoughts or perceptions

– recurrent nightmares– acting or feeling as if the trauma were recurring

• dissociative flashbacks• sense of reliving the experience• illusions• hallucinations

Re-experiencing the trauma

With exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event:

– physiological reactivity – intense psychological distress

Avoidance and Numbing

Avoid reminders of trauma • thoughts, feeling, conversations• activities, places, people• unable to recall key aspects

Avoidance and Numbing

Emotional withdrawal: • reduced involvement in sig. activities • sense of detachment from others• restricted range of affect• sense of foreshortened future

Avoidance and Numbing

The patient is in survival mode – Avoidance: a way to keep away from

further danger which still feels present– The individual may feel safe but is

isolated and withdrawn from life

(Jan Ewing workshop June 2008)

Physical arousal/tension

– hypervigilant (“on guard”); – exaggerated startle response;– irritability & angry outbursts; – poor concentration;– difficulty falling or staying asleep

Physical arousal/tension

– Keeps the patient alert & prepared for the presence of danger

• know where the Exits are• sit with their back to the wall• need to be able to see and monitor everything

– “The threat detector” is so strong, the slightest “whiff” of a threat results in hyperarousal (Jan Ewing 2008)

PTSD Diagnosis (DSM-IV)

– Duration > one month– Associated with:

• significant distress or • impairment in functioning

Complex PTSD

• Genesis: CSA• PTSD symptoms +

– damage to attachment & self-systems– serious difficulties with affect regulation

& self-soothing– more likely to use dissociation as a

survival strategy + substance abuse

Dr Jan Ewing Oct 2008

Borderline Personality Disorder

Genesis:– Trauma may be important, or– Hypersensitive child + invalidating

environment

Dr Jan Ewing Oct 2008

• A (1) Abandonment • M (6) Mood instability (marked reactivity of mood)• S (5) Suicidal (or self-mutilating) behaviour • U (2) Unstable and intense relationships • I (4) Impulsivity (in two potentially self-damaging areas:

substance use; spending; sex; shoplifting; binge eating) • C (8) Control of anger• I (3) Identity disturbance • D (9) Dissociative (or paranoid) symptoms that are

transient and stress related• E (7) Emptiness (chronic feelings of)

Borderline personality disorder: A.M. SUICIDE (five criteria)Borderline personality disorder: A.M. SUICIDE (five criteria)

“Borderline individuals are the psychologicalequivalent of the 3rd-degree burn patient.They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering….”

Marsha Linehan 1993

What treatments work best?

Traditional SUD treatment

• Patients with and without PTSD improve substance use, mental & physical health

• PTSD group:– poorer physical & mental health– poorer occupational functioning– residual PTSD symptoms which

often trigger relapse– PTSD needs focussed treatment

Teesson & Mills Workshop 2006

NDARC

• Integrated treatment studies– PTSD & illicit drugs– PTSD & alcohol

Recruitment

Prevalence PTSD, depression, suicidality inpatients with SUD’s

• Dr Glenys Dore• Dr Katherine Mills• Robin Murray• Professor Maree Teesson• Philipa Farrugia• Anne-Marie Hall

Methodology

Screening Questionnaires:– all admissions over 9 month period– excluding readmissions

At admission or soon after:– Modified PsyCheck – suicidality– Zung Self-rating Depression Scale

• 20 items, self-report

Methodology

Trauma screening questionnaire– Trauma situations– 10 item screener

• based on most traumatic event• excluded grief/loss

Trauma situations

1. Seriously physically attacked or assaulted

2. Threatened with a weapon, held captive, kidnapped

3. Involved in life-threatening car accident

4. Involved in fire, flood, natural disaster

5. Witnessed someone badly injured or killed

6. Rape

7. Sexual molestation

8. Tortured or victim of terrorists

9. Direct combat in war situation

10. Person’s response involved intense fear, helplessness or horror

Trauma Screening Questionnaire (TSQ)

Please indicate (Yes/No) whether or not you have experienced any of the following at least twice in the past month:

25

1. Upsetting thoughts or memories about the event that have come into your mind against your will

2. Upsetting dreams about the event

3. Acting or feeling as thought the event were happening again

4. Feeling upset by reminders of the event

5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event

6. Difficulty falling or staying asleep

7. Irritability or outbursts of anger

8. Difficulty concentrating

9. Heightened awareness of potential dangers to yourself and others

10. Being jumpy or being startled at something unexpected

Results

• Total no. admissions = 304

• Completed data sets (all 3 Q’s)

= 253 (83.2%)

Sample characteristics

• 66.8% male• Mean age 37.29 (SD 10.54) years• Australian born 85.4%: ATSI 3.2%• 21% employed; 79% benefits• Main living situations:

– 24.9% alone; 23.3% parents– 6.7% homeless

Sample characteristics

Principal drug of concern:• alcohol 46.2%• opioids 26.1% • stimulants 9.5%• cannabis 9.1%, BZD 9.1%• 60.6% reported more than

one drug of concern• 34.6% IDU within last 3 months

Rates of trauma exposure

• Any type of trauma = 80.6%

(male 79.9%, female 82.1%)

• ANSMHWB = 57%

(male 64.5%, female 49.5%)

Creamer M et al. Psychol Med 2001

Rates of trauma exposure

• Mean no. of trauma types = 2.55• ANSMHWB: 55% 2 or more trauma

events

• Mean age first trauma = 14.12 years (similar males & females)

Creamer M et al. Psychol Med 2001

Rates of trauma exposure

Sex differences:• similar rates of exposure to any

trauma (male 79.9%, female 82.1%)• women 8.8 x more likely to have

been raped• women 4.67 x more likely to have

been sexually molested

Rates of trauma exposure

• Exposed to significantly more trauma types if:– polysubstance use– BZD main drug of concern

• Polysubstance use associated with– significantly younger age of 1st

trauma (12.49 vs 16.81 years)

Natural disaster

Trauma Situations

Trauma Situations

Sexual assault/rape

Frequency of trauma types

PTSD prevalence

Screened positive for current

PTSD = 44.9%

Lifetime history PTSD• 7.8% general pop’n (NCS):

–women 2x as likely as men: –(10.4% vs 5%)

• USA Vietnam vets: 28.9%

Trauma Situations!!!!

Screened positive for current

PTSD = 44.9%

Treatment seeking, with SUD’s:• 36 – 50% lifetime PTSD• 25 – 42% current PTSD• 41% ATOS

– Jacobsen LK, Am J Psych 2001

PTSD

Associated with• younger age of first trauma exposure• exposure to more trauma types• specific trauma types:

Odds Ratio

Raped 3.43

Witnessed serious injury or death 2.91

Natural disasters 2.57

Assaulted or attacked physically 2.45

PTSD

Not significantly associated with:• age• sex (Males 40.9%, Females 53%)• principal drug of concern• multiple drugs of concern

Depression & Suicidality

PTSD group significantly more likely to have:– moderate to severe depression– lifetime history self harm/suicide attempt/s

PTSD No PTSD Odds Ratio

Depression 33.3% 12.1% 3.6

Suicidality 48.6% 27.2% 2.4

Comorbidity

Comorbidity

50% with PTSD meet criteria for 3 or more other psychiatric diagnoses (NCS) commonly:– affective disorders (mainly

depression)– substance use disorders– other anxiety disorders

Brady KT et al. J Clin Psych 2000

Comorbidity

Patients may need treatment for multiple disorders including:– other anxiety disorders– major depressive disorder

Higher rates suicidality/self harm– suicide risk assessment &

management important Brady KT et al. J Clin Psych 2000

Trauma exposure & PTSD

Study groupHigh rates trauma exposure (81%)High rates current PTSD (45%) vs general

popn (8%)

PTSD associated with • greater trauma exposure• younger age 1st trauma• specific trauma types• moderate to severe depression• history of self-harm or attempted suicide

Relationship between SUD & PTSD

• Substance used to modify PTSD symptoms (“self medication”)

• As dependence develops, physiologic arousal from substance withdrawal exacerbates PTSD symptoms

• This exacerbation contributes to relapse• Substance using lifestyle: risk of

trauma exposure• Both disorders maintain/exacerbate the

other

Jacobson LK et al Am J Psych 2001 Mills K. Of Substance 2008

Recommendations

– Screen for PTSD, depression, suicidality– Remember avoidance part of disorder– If you don’t ask, they may not tell you– Normalise the patient’s response to the

trauma: validates their feelings & experience

– Awareness of triggers may facilitate best management eg male case manager

Ouimette et al 1998;

Mills et al 2009

Clinical implicationsfor patients in the unit?

PTSD symptoms often increase during withdrawal

– No longer masked by D & A use– Autonomic hyperactivity in withdrawal

exacerbates hyperarousal symptoms– Important to educate patients about

likely increase in symptoms– Provide tools/strategies to manage

symptoms

Strategies to manage PTSD symptoms

• Medication for anxiety

• Progressive muscle relaxation

• Breathing techniques

• Visualisation and imagery

• Grounding e.g. mindfulness

What about longer term treatment?

Treatment Phases

Establish therapeutic alliance/trust: – first step in any treatment– may take years– may be all you can do– may be impossible with some patients

where the patient’s transference is unmanageable

Dr Jan Ewing Oct 2008

Treatment Phases

Psychoeducation/normalisation

Symptomatic treatment – mood & affect management

- medication, - anger management- relaxation, grounding, CBT

Dr Jan Ewing Oct 2008

Treatment Phases

Behavioural desensitisation to reminders – CBT with graduated exposure

Imaginal exposure – trauma re-processing

- Imagery - EMDR

Dr Jan Ewing Oct

2008

Treatment PTSD & SUD– Gold standard PTSD: exposure– Traditionally considered inappropriate

with SUD: • fear >emotions trigger relapse• impaired cognitions SUD impair

ability for imaginal exposure• belief extended recovery needed

Teesson & Mills Workshop 2006

However….

Preliminary studies found integrated treatment• safe & effective• SUD and PTSD same time,

same therapist• Includes exposure therapy, CBT

Teesson & Mills Workshop 2006

Is exposure therapy for post traumatic stress disorder (PTSD)

efficacious among people with substance use disorders (SUD)?

Results from a randomised controlled trial

Katherine L Mills1, Maree Teesson1 , Emma Barrett1, Sabine Merz1, Julia

Rosenfeld1, Philippa Farrugia1, Claudia Sannibale1, Sally Hopwood2,

Amanda Baker3, Sudie Back4, Kathleen Brady4

1 National Drug and Alcohol Research Centre, University of New South Wales2 Traumatic Stress Clinic, Westmead Hospital

34 Centre for Brain and Mental Health Research, University of Newcastle4 Department of Psychiatry, Medial University of South Carolina

COPE v. IICOPE v. II

• NDARC conducted a randomised controlled trial of a modified version of CTPSD: Concurrent Treatment with Prolonged Exposure version II (COPE v2; Mills et al 2007).

• Target population: Individuals with any drug use disorder and multiple sources of trauma

• Sessions: 13 sessions with a clinical psychologist• Format: Individual• Program: CBT with imaginal and in vivo exposure

The first randomised controlled trial of exposure therapy among individuals with SUDs

COPE Treatment componentsCOPE Treatment components

• CBT for substance use (Sessions 1-4 and throughout)• Psychoeducation relating to both disorders and their

interaction (Sessions 1-4)• In vivo exposure (Sessions 5-12)• Imaginal exposure (Sessions 6-12)• Cognitive therapy for PTSD (Sessions 8-12)• Review, after care plan, termination (Session 13)

Both groups may receive treatment as usual for their substance use in the community (e.g., detox, residential rehabilitation, maintenance pharmacotherapies, counselling etc)

Randomised controlled trialRandomised controlled trial

Across the 9 mth follow-up period:

– Both groups evidenced improvements in their • Substance use• Severity of dependence• PTSD symptoms• Depression• Anxiety • General mental health

ConclusionConclusion

THEY DID NOT GET WORSE!

Participants randomised to COPE demonstrated:– significantly greater improvements in PTSD

symptoms – particularly avoidance and hyperarousal symptoms

These findings provide evidence in support of

treating PTSD among people with SUDs using COPE (Mills et al., 2007).

ConclusionConclusion

Questions for discussion

PTSD treatment really helps• How & where can we access it

for our patients?• Should all D & A workers be

trained in trauma counselling?• How best to support staff when

dealing with trauma issues?