Transcript Triple Trouble: Addiction & What Else? Co

Triple Trouble: Female,
Addicted & What Else? Cooccurring 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 experience
2. Raped
3. Sexual assault other than rape
injured
4. Held captive, tortured,
kidnapped
5. Shot or stabbed
6. Mugged, held up,
threatened with a weaon
7. Badly beaten up
8. Serious car or motor vehicle
crash
9. Any other serious accident
10. Fire, flood, earthquake,
or other natural disaster
11. Diagnosed with a life-threatening personal
illness
12. Child of yours diagnosed with a lifethreatening illness
13. Witnessed someone being killed or seriously
14. Unexpectedly discovering a dead or
body
15. Learned that a close friend/relative
was raped or sexually assaulted
16. Learned that a close friend/relative or
was seriously physically attacked
17. Learned that a close friend/relative
was seriously injured in a motor
vehicle accident
18. Learned that a close friend/relative
was seriously injured in any other
accident
19. Sudden, unexpected death of a close or injury
friend or relative
20. Heard gunshots in your neighborhood
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):1114-1119
Prevalence of Traumatic
Events
M ale
40
Female
36
30
25
%
19
20
15
14
12
11
10
7
9
7
6
3
0
0
Witness
Accident
Threat
Attack
Molestation
Combat
1
Rape
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-1986-1988)
– 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 - 39.2%
– Current - 11.2%
• 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 decisionmaking rules for the PTSD diagnosis since
there are not exclusionary criteria
Lifetime Prevalence of other
Disorders by Hx PTSD
Exposure
PTSD
(n=93)
MDD
Any Anxiety
Alcohol A/D
Drug A/D
36.6%
58.1%
31.2%
21.5%
Exposed Not
Only
Exposed
(n=301) (n=613)
13.0%
26.3%
23.3%
13.3%
10.1%
21.9%
19.1
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
PTSD
GAD
PD
M DD
US Population
100
83
81
75
65
SF-36
61
54
45
50
38
38 38
34
28
25
20
35
29
21
0
Role Emotional
Vitality
Social Function
Impaired Health Functioning
PTSD
Panic
GAD
M DD
US Population
100
SF-36
75
50
25
0
Pain
Role Physical
Physical
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
<Gender><Victim>
<Substance Use>
<HIV><HCV>
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
www.drugabuse.gov
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
Prevention Programs Should . . . .
. .Target all Forms of Drug Use
. . . and be Culturally Sensitive
www.drugabuse.gov
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 (1st 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
Prevention Programs Should . . . .
Include Interactive Skills-Based
Training
 Resist drugs
 Strengthen personal
commitments against drug use
 Increase social competency
 Reinforce attitudes against drug
use
www.drugabuse.gov
Prevention Programs Should be. . . .
Family-Focused
 Provides greater impact than
parent-only or child-only
programs
 Include at each stage of
development
 Involve effective parenting skills
www.drugabuse.gov
Components of Comprehensive
Drug Addiction Treatment
www.drugabuse.gov
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