ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER

Alcohol Medical Scholars Program @ 2003 11

ALCOHOLISM AND POSTTRAUMATIC STRESS

DISORDER

Joe E. Thornton, M.D.

Alcohol Medical Scholars Program @ 2003Alcohol Medical Scholars Program @ 2003 22

Significance

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


Dilemma

People may increase alcohol use in response to trauma

Alcoholism could temporarily mimic PTSD

Alcoholism makes preexisting disorders (including PTSD) worse


Lecture Overview

Clinical information on alcoholism Clinical information on PTSD Strategies for diagnoses and

treatment Strategies for primary care treatment

interventions


ABSTABSTNON-NON-PROBPROBUSEUSE

AT-AT-RISKRISKUSEUSE

ABUSEABUSE DEPDEP

UseConsequencesRepetitionLoss of control, preoccupation, compulsivity, physical dependence

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+--

+-/+-

+++

+++++

Alcohol Use Spectrum


Alcoholism Definition

Alcoholism = Alcohol Use Disorders

DSM-IV Alcohol Use Disorders Alcohol dependence Alcohol abuse Alcoholism may be complicated by

alcohol induced disorders


Alcohol Dependence

In the past 12 months 3+ of: Tolerance Withdrawal More use Loss of control Significant time Giving up important activities Continued use


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


Alcoholism Prevalence

AbuseAbuse Men 13 %Men 13 % Women 6 %Women 6 %

DependenceDependence Men 20 %Men 20 % Women 8 %Women 8 %


Clinical Course

Early milestones similar to populationEarly milestones similar to population First drink ~age 13First drink ~age 13 First intoxication ~age 16First intoxication ~age 16 First problem ~age 21 First problem ~age 21

40% of all drinkers have some 40% of all drinkers have some minor problem at some timeminor problem at some time


Clinical Course

Dependence ~age 28 Variable course Frequent periods of abstinence Any given month ~50% of alcoholics

are abstinent Spontaneous remissions ~20%


Medical Morbidity

Dependence cuts 15 years off the lifespan

Deaths from Heart disease Cancer Accidents Suicide


Psychiatric Symptoms in Alcoholism

Almost 100% have insomnia and bad dreams

~ 40% experience Depression Anxiety Psychosis Other alcohol induced disorders

Symptoms resolve with abstinence


NoneNoneTransient Transient

or no or no symptomssymptoms

Acute Acute Stress Stress

DisorderDisorderPTSDPTSD ++

TraumaConsequencesImpairment > 30dRe-experience, arousal and avoidant symptoms Co-occurring syndromes

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+-/+-

++-

++++

+++++++++

Trauma Spectrum


PTSD Definition

DSM-IV Posttraumatic stress disorderHistory of traumatic event: Person experienced, witnessed, or

was confronted with a disturbing event

Response was intense fear, helplessness, or horror


PTSD Definition

Re-experienced as 1+ symptoms

Arousal as evidenced by 2+ symptoms

Avoidance indicated by 3+ symptoms


PTSD Definition

Duration >1 month

Symptoms significant


PTSD Prevalence

~70% persons in US exposed to 1+ trauma

~11% of trauma-exposed persons develop PTSD

Prevalence of PTSD: Men – 5% Women – 10%


Risks for PTSD Trauma severity Prior trauma Prior psychiatric history Peritraumatic dissociation Autonomic hyperarousal Acute stress symptoms


PTSD Clinical Course

Onset follows Acute Stress Disorder Variable course Spontaneous remission uncommon Physical symptoms common No definitive link with physical health

or mortality


PTSD and Alcoholism

Community patients with PTSD have Community patients with PTSD have 2x alcoholism2x alcoholism

Patients seeking treatment for Patients seeking treatment for alcoholism have 3x PTSDalcoholism have 3x PTSD

Substance dependence adolescent Substance dependence adolescent inpatients have 5x PTSDinpatients have 5x PTSD

Inpatient alcohol rehabilitation adult Inpatient alcohol rehabilitation adult women have 5x PTSD women have 5x PTSD


Symptoms

Insomnia Nightmares Irritability GI distress Tachycardia Dyspnea Tremor

Fatigue Concentration

impaired Poor recall Decreased

interests Emotional blunting


Diagnostic Strategies

Age of onset alcoholism Periods of abstinence Age of trauma ? PTSD existed before alcoholism or

after 3+ months of abstinence Findings dictate treatment


Alcoholism Treatment

Cognitive/behavioral 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)


PTSD Treatment

Cognitive/behavioral (e.g. Exposure Therapy) 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


Alcoholism and PTSD Wait and Treat

Achieve abstinence and monitor PTSD symptoms

Control PTSD symptoms and monitor alcohol abstinence

Sequential treatment Treat the most disabling syndrome first If second syndrome still present after time

then treat


Alcoholism and PTSD Comprehensive Treatment

Coordinated treatmentsCoordinated treatments Alcohol counselors communicate Alcohol counselors communicate

with therapists treating PTSDwith therapists treating PTSD

Integrated treatmentsIntegrated treatments Alcohol counselors and PTSD Alcohol counselors and PTSD

therapists work as a teamtherapists work as a team


Treatment in Primary Care

Assess symptoms Assess symptoms Assess in detail patient’s response to Assess in detail patient’s response to

symptomssymptoms Over the counter medicinesOver the counter medicines Alcohol or other substance useAlcohol or other substance use

Psychosocial historyPsychosocial history Behavioral health historyBehavioral health history


Alcoholism Treatment in Primary Care

Quantity /frequency interviewQuantity /frequency interview How many days a week do you drink? How many days a week do you drink? How much on typical drinking day? How much on typical drinking day? What is the most you had had to drink What is the most you had had to drink

on one day?on one day? Education about at-risk drinkingEducation about at-risk drinking

Men > 5 drink/day or 14 drinks/weekMen > 5 drink/day or 14 drinks/week Women > 3 drinks/day or 7 drinks/weekWomen > 3 drinks/day or 7 drinks/week


Brief Treatment

Risk behavior education Risk behavior education interventionsinterventions

Stage specific messagesStage specific messages AbstinentAbstinent Non-problem useNon-problem use At-risk useAt-risk use Abuse, dependence Abuse, dependence


Counseling (FERNSS)

FeedbackFeedback EducationEducation RecommendationRecommendation NegotiationNegotiation Secure agreementSecure agreement Set follow-upSet follow-up


Summary

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

Documents

ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER