Transcript Alcohol Use Disorders and Posttraumatic Stress Disorder

ALCOHOLISM AND
POSTTRAUMATIC STRESS
DISORDER
Joe E. Thornton, M.D.
Alcohol Medical Scholars Program @ 2003
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Significance
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Alcoholism and Posttraumatic
Stress Disorder (PTSD) are common
Symptoms overlap
Co-occurrence increases severity
Most physicians know little about
either but will treat at-risk patients
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Dilemma
People may increase alcohol use
in response to trauma
 Alcoholism could temporarily
mimic PTSD
 Alcoholism makes preexisting
disorders (including PTSD) worse
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Lecture Overview
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Clinical information on alcoholism
Clinical information on PTSD
Strategies for diagnoses and
treatment
Strategies for primary care
treatment interventions
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Alcohol Use
Spectrum
Use
Consequences
Repetition
ABST
NONPROB
USE
-
+
-
ATRISK ABUSE DEP
USE
+
-/+
-
+
+
+
+
++
+
Loss of control, preoccupation, compulsivity, physical dependence +
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Alcoholism Definition
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Alcoholism = Alcohol Use Disorders
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DSM-IV Alcohol Use Disorders
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Alcohol dependence
Alcohol abuse
Alcoholism may be complicated by
alcohol induced disorders
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Alcohol Dependence
In the past 12 months 3+ of:
 Tolerance
 Withdrawal
 More use
 Loss of control
 Significant time
 Giving up important activities
 Continued use
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Alcohol Abuse
Repetitive pattern of harmful
behaviors 1+ of:
 Failure to fulfill major role obligations
 Physically hazardous use
 Legal problems related to use
 Interpersonal problems related to
use
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Alcoholism Prevalence
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Abuse
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Men
13 %
Women 6 %
Dependence
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Men
20 %
Women 8 %
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Clinical Course
Early milestones similar to population
 First drink
~age 13
 First intoxication ~age 16
 First problem
~age 21
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40% of all drinkers have some
minor problem at some time
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Clinical Course
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Dependence ~age 28
Variable course
Frequent periods of abstinence
Any given month ~50% of alcoholics
are abstinent
Spontaneous remissions ~20%
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Medical Morbidity
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Dependence cuts 15 years off the
lifespan
Deaths from
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Heart disease
Cancer
Accidents
Suicide
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Psychiatric Symptoms in
Alcoholism
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Almost 100% have insomnia and
bad dreams
~ 40% experience
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Depression
Anxiety
Psychosis
Other alcohol induced disorders
Symptoms resolve with abstinence
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Trauma Spectrum
Acute
Transient Stress
PTSD
or no
None
Disorder
symptoms
+
-/+
-
+
+
-
Trauma
Consequences Impairment > 30d
Re-experience, arousal and avoidant symptoms
Co-occurring syndromes
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+
+
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+
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+
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PTSD Definition
DSM-IV Posttraumatic stress disorder
History of traumatic event:
 Person experienced, witnessed, or
was confronted with a disturbing
event
 Response was intense fear,
helplessness, or horror
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PTSD Definition
Re-experienced as 1+ symptoms
Arousal as evidenced by 2+ symptoms
Avoidance indicated by 3+ symptoms
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PTSD Definition
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Duration >1 month
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Symptoms significant
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PTSD Prevalence
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~70% persons in US exposed to 1+
trauma
~11% of trauma-exposed persons
develop PTSD
Prevalence of PTSD:
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Men
– 5%
Women – 10%
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Risks for PTSD
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Trauma severity
Prior trauma
Prior psychiatric history
Peritraumatic dissociation
Autonomic hyperarousal
Acute stress symptoms
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PTSD Clinical Course
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Onset follows Acute Stress Disorder
Variable course
Spontaneous remission uncommon
Physical symptoms common
No definitive link with physical health
or mortality
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PTSD and Alcoholism
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Community patients with PTSD have
2x alcoholism
Patients seeking treatment for
alcoholism have 3x PTSD
Substance dependence adolescent
inpatients have 5x PTSD
Inpatient alcohol rehabilitation adult
women have 5x PTSD
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Symptoms
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Insomnia
Nightmares
Irritability
GI distress
Tachycardia
Dyspnea
Tremor
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Fatigue
Concentration
impaired
Poor recall
Decreased
interests
Emotional blunting
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Diagnostic Strategies
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Age of onset alcoholism
Periods of abstinence
Age of trauma
? PTSD existed before alcoholism or
after 3+ months of abstinence
Findings dictate treatment
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Alcoholism Treatment
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Cognitive/behavioral
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Increase motivation
Help restore functioning
Relapse prevention
Intense treatment 2-4 weeks
Then less intense for 6+ months
Self-help groups
Limited role for medications (naltrexone)
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PTSD Treatment
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Cognitive/behavioral (e.g. Exposure Therapy)
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Patient confronts event
Patient educated about common reactions to
trauma
Patient is trained in behavioral symptom
management
Patient progressively masters the symptom
response
Medications
 SSRI antidepressants
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Alcoholism and PTSD
Wait and Treat
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Achieve abstinence and monitor PTSD
symptoms
Control PTSD symptoms and monitor
alcohol abstinence
Sequential treatment
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Treat the most disabling syndrome first
If second syndrome still present after time
then treat
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Alcoholism and PTSD
Comprehensive Treatment
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Coordinated treatments
 Alcohol counselors communicate
with therapists treating PTSD
Integrated treatments
 Alcohol counselors and PTSD
therapists work as a team
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Treatment in Primary Care
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Assess symptoms
Assess in detail patient’s response to
symptoms
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Over the counter medicines
Alcohol or other substance use
Psychosocial history
Behavioral health history
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Alcoholism Treatment in
Primary Care
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Quantity /frequency interview
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How many days a week do you drink?
How much on typical drinking day?
What is the most you had had to drink
on one day?
Education about at-risk drinking
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Men > 5 drink/day or 14 drinks/week
Women > 3 drinks/day or 7 drinks/week
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Brief Treatment
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Risk behavior education interventions
Stage specific messages
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Abstinent
Non-problem use
At-risk use
Abuse, dependence
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Counseling (FERNSS)
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Feedback
Education
Recommendation
Negotiation
Secure agreement
Set follow-up
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Summary
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Alcoholism and PTSD commonly co-occur
Diagnosis of both disorders is essential for
successful treatment
Comprehensive treatment incorporates the
interactions of symptoms with treatment
All physicians have treatment opportunities
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