Understanding Traumatic Stress:

Implications for Professionals Working

with Addiction

Steve Wonderlich, Ph.D.

University of North Dakota, The Neuropsychiatric Research Institute (NRI), Sanford

Nicola Herting, Ph.D.

Red River Children’s Advocacy Center

Jennifer Boub, M.B.A.

Treatment Collaborative for Traumatized Youth (TCTY), NRI

Part I: Trauma 101

Defining Trauma

Any witnessed or experienced event that threatens the life or physical integrity of the child

or someone critically important to the child

ACUTE

An isolated traumatic event

e.g., car accident, dog bite, date rape

CHRONIC

Multiple traumatic events, often over a long period of time

e.g., repeated physical abuse

COMPLEX

Multiple traumatic events that begin at a

very young age and are caused by the adults

who should have been caring for and protecting

the child

Types of Childhood Trauma

Sexual Abuse Physical AbuseEmotional

AbuseNeglect

Sexual Exploitation

Witness Domestic Violence

Community/ School

ViolenceBullying

Death of Loved One

SuicideMotor

Vehicle/Travel Accidents

Weather-Related Events

Natural Disasters

FiresMedical Trauma

War

Prevalence of Trauma

• Each year in the U.S., more than 1,500 children – nearly two children per 100,000 – die of abuse or neglect.

• In 2010, 695,000 unique children were substantiated victims of child maltreatment .

• In a national sample of children, over 60% were exposed to violence or abuse in their homes or communities during the past year.

• A national study of adult foster care alumni found that 25.2% had PTSD, nearly double the rate of U.S. war veterans.

• 1 out of 4 children experience a traumatic event before the age of 16

(U.S. Department of Health and Human Services, 2011; Finkelhor et al., 2009; Pecora et al., 2005)

Adverse Childhood Experiences

1. Child physical abuse.

2. Child sexual abuse.

3. Child emotional abuse.

4. Emotional neglect.

5. Physical neglect.

6. Mentally ill, depressed or suicidal person in the home.

7. Drug addicted or alcoholic family member.

8. Witnessing domestic violence against the mother.

9. Loss of a parent to death or abandonment, including abandonment by parental divorce.

10. Incarceration of any family member for a crime.

Source: Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ... Marks, J. S. (1998). Relationship

of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood

Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245-258.

The ACE Study(Felitti et al., 1998)

Smoking

Obesity

Depression

Suicide Gesture

Alcoholism

Illicit Drugs

Injectable Drugs

Sexual Promiscuity

STD

2.2

1.6

4.6

12.2

7.4

4.7

10.3

3.2

2.5

Disease

4 or More Adversities

(Odds Ratio)

The ACE Study(Felitti et al., 1998)

Heart Disease

Cancer

Stroke

Bronchitis/Emphysema

Diabetes

Hepatitis

Fair/Poor Health

2.2

1.9

2.4

3.9

1.6

2.4

2.2

Disease

4 or More Adversities

(Odds Ratio)

11

Long-Term Trauma Impact–ACE Pyramid: CDC

Early Death

Disease, Disability, and

Social Problems

Adoption of Health-risk Behaviors

Social, Emotional, and Cognitive Impairment

Disrupted Neurodevelopment

Adverse Childhood Experiences

Mechanisms by Which Adverse Childhood Experiences InfluenceHealth and Well-being Throughout the Lifespan

Conception

Death

Part II: Thinking More About Substance Use After Trauma

Is the Mere Presence of Trauma Linked to Substance Use Disorders

• Traumatized teens 3x more likely to have SUD

• 70% of teens receiving CD treatment report trauma histories

• ACE findings• ETOH (OR = 7.4)

• Injectable drugs (OR = 10.3)

NSA, 2003

Anda & Felitt, 2009

• So will all trauma survivors develop SUD’s?

• Could it be that it is the psychological reaction after trauma that increases risk?

• This is important! Not all trauma survivors are at risk. So determining who is most at risk after trauma is key.

Could PTSD be a Helpful Idea When

Thinking About the Link Between Trauma

and Substance Use Disorders?

Posttraumatic Stress Disorder (PTSD)

A. Exposure to a traumatic event

B. Intrusion symptoms (memories, nightmares, flashbacks, etc.)

C. Persistent avoidance of stimuli associated with the trauma

D. Negative alterations in cognitions and mood that are associated with the traumatic event

E. Alterations in arousal and reactivity that are associated with the traumatic event

Posttraumatic Stress Disorder (PTSD)

F. Persistence of symptoms for more than one month

G. Significant symptom-related distress or functional impairment

H. Not due to medication, substance or illness

Common PTSD Reactions in Children

RE-EXPERIENCING

• Memories of event

• Nightmares

• Play resembling the trauma

AVOIDANCE• Avoiding people or

places

• Denial

NEGATIVE EMOTIONS/

COGNITIONS

• Numbing

• Socially detached

• Loss of interest

• Negative thoughts and beliefs

PHYSICALLY ACTIVATED

• Physical symptoms

• Sleep problems

• Irritable

• Clingy/whining behavior

PTSD

If you develop PTSD after trauma, are you more at risk for SUD?

PTSD and SUD

• 59% of teens with PTSD develop substance use problems

• Teens with PTSD and SUD have more severe interpersonal and internalizing problems than teens with SUD only. They also use more clinical services.

• Exposure to trauma cues in CD patients with PTSD increases to cravings for substance!

Copeland, et al 2007

Susrey, et al., 2012

Coffey et al., 2010

Does PTSD Influence SUD Treatment

• Several studies among substance users suggest PTSD predicts:

• More relapse

• Faster relapse

• Less improvement on SUD

• More distress at follow-up

Substance Use and Post-Traumatic Stress Disorders: Symptom Interplay and Effects on Outcome

(Read et.al., 2004)

• 133 participants receiving SUD treatment• 69% AUD

• 34% Opiates

• 23% Cocaine

• 19% Cannabis

• At admission• 95% had a trauma

• 41% had PTSD

Substance Use and Post-Traumatic Stress Disorders: Symptom Interplay and Effects on Outcome

• Those with SUD and PTSD• Longer duration of SUD

• More comorbidity

• Effect of PTSD on clinical outcome• PTSD did not predict overall SUD outcome at 6 month follow up,

but…

• At 6 month f/u:

PTSD + PTSD −Days Abstinent 76 90

Psychiatric Distress 153.2 58

Model 1: Self Medication Hypothesis

Trauma PTSD SUD

Reduces affect

“If I don’t do drugs, I feel like I’m going to go insane. Because I have all these thoughts and all this pain in my heart and I can’t get rid of it, you know? Drugs are the only thing that take that away. That’s why I do drugs. Because it keeps me, not happy, but it keeps me from being so sad that I want to die.”

Model 2: SUD as Risk for Trauma

SUD Risky Environment Trauma

Choices

PTSD

Model 2

• 50% of PTSD and SUD report SUD preceded PTSD

• 20% of CD teens drove while drunk in last year

NCTSN

SAMHSA, 2007

Part III: Treatment of Comorbid Substance Use Disorder and PTSD

STEP ONEScreening for PTSD

NCTSN Guidelines to Trauma-Informed Screening and Assessment

• Trauma-informed screening refers to a brief, focused inquiry to determine whether an individual has experienced specific traumatic events or reactions to trauma

• Performed by frontline workers or mental health clinicians

• Trauma assessment is a more in-depth exploration of the nature and severity of the traumatic events, the impact of those events, current trauma-related symptoms and functional impairment

• Performed by mental health clinicians

Screening Youth for PTSD Symptoms

Internalizing Symptoms/PTSD

1. MN Trauma Screen

2. Child Trauma Screen (CTS)

Externalizing Symptoms

1. Pediatric Symptom Inventory-17

MN Trauma Screen Measure

Screening Adults for PTSD Symptoms

PCL-5

STEP TWO

Treat Comorbid PTSD and SUD in an Integrated Approach

What Helps People with PTSD?

PTSD Treatment Efficacy

Effect Size (Hedge's g )

-1 -0.5 0 0.5 1 1.5 2

Primarily CognitiveMixed Exposure

Primarily ExposureSkills-based/SIT

EMDRPsychodynamic

HypnotherapySelf-help

GroupBiofeedbackAcupunctureVenlafaxine

Alpha blockersSSRIsTCAs

MAO-IsOther Antidepressants

AtypicalBenzodiazepinesMood Stabilizers

Watts et al., 2013; cited by Monson, 2017

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

(Cohen, Mannarino, & Deblinger, 2006)

Empirical Support for TF-CBT

• TFCBT has greater impact compared to other treatments

• PTSD symptoms

• Depression, anxiety

• Internalizing, externalizing

• Sexualized behavior problems

• Behavior problems

• Abuse-related cognitions

• For reviews see: de Arellano, et al., 2014; Dorsey, Briggs & Woods, 2011; Silverman, et al., 2008

Cognitive Processing Therapy (CPT) for PTSD

(Resnick, Monson, & Chard, 2006)

How Does CPT Work?

Avoidance is challenged

Expression & dissipation

of natural emotions

Acceptance of the reality of what

happened & resolution of self-blame leads to

changes in secondary emotions

Clients learn that traumatic events have

negative consequences but don’t have to have

big implications

Prolonged Exposure (PE) Therapy for PTSD

(Foa, Hembree, Rothbaum, 2007)

Prolonged Exposure Therapy for PTSD

Short-term evidence-based psychotherapy

A specific CBT protocol

Primarily exposure based

Helps to process traumatic events and reduce

trauma-induced psychological disturbances

Clinically significant improvement in about 80% of

patients with chronic PTSD

How Does PE Work… Exposure

Seeking Safety

(Najavits, 2002)

Seeking Safety Therapy for PTSD

Short-term evidence-based psychotherapy

Treatment for BOTH trauma and substance use

Manualized treatment that is flexible in delivery

Focused on eliminating substance use, reduce

PTSD, and increase safety

Can be delivered by anyone trained in the model,

no specific license or degree required.

Seeking Safety is Evidence-Based

It is the only model thus far that has outperformed

controls on both PTSD and substance use at end

of treatment in randomized and/or controlled trials.

Cost Benefit Analysis

Screened for PTSD

Now you need a provider…

Where do you look?

YOUTH PROVIDERS

LOCAL

• TCTY• https://www.tcty-nd.org/clinician-list/

• AMBIT Network

• http://www.cehd.umn.edu/fsos/research/ambit/provider.asp

NATIONAL

• TFCBT Provider Roster• https://tfcbt.org/members/

• Seeking Safety Provider List• https://www.treatment-innovations.org/locate-ss.html

Clinical Centers with Clinicians already trained by TCTY in TF-CBT

Belcourt

Devils Lake

Center/Agency with TCTY Trained

Clinician(s)

Sentinel Butte

ADULT PROVIDERS

LOCAL

• VA PTSD Treatment• https://findtreatment.samhsa.gov/locator

NATIONAL

• CPT Provider Roster: • https://cptforptsd.com/cpt-provider-roster/

• PE Provider Roster• https://www.med.upenn.edu/ctsa/pedirectory.html

• Seeking Safety Provider List• https://www.treatment-innovations.org/locate-ss.html

Thank You!

Questions