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Post-Traumatic Stress Disorder (PTSD) & Alcohol Use Disorder (AUD)

This lecture delves into the diagnosis, prevalence, and treatment of Post-Traumatic Stress Disorder (PTSD) and Alcohol Use Disorder (AUD). It covers clinical issues related to their co-morbidity and presents a clinical case study. The presentation also discusses Acute Stress Disorder, markers of heavy drinking, and the course of AUD.

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Post-Traumatic Stress Disorder (PTSD) & Alcohol Use Disorder (AUD)

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  1. Post-Traumatic Stress Disorder (PTSD) & Alcohol Use Disorder (AUD) J. David Stiffler, MD Department of Psychiatry New York University School of Medicine AMSP 2018

  2. PTSD and AUD Are both common PTSD lifetime ~ 10% AUD lifetime ~ 12% Having PTSD or AUD ↑s risk of the other Can be difficult to Dx Are effective Rx for each AMSP 2018

  3. Lecture Covers • Dx, prevalence & course of PTSD • Dx, prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018

  4. Clinical Case: Steve Physically abused 8-11yo Family history of substance use disorders Cannabis problems as teen  ↓ grades Enlisted in Army at 18yo  Iraq x2 AMSP 2018

  5. Lecture Covers • Dx, prevalence & course of PTSD • Dx, prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018

  6. ACUTE STRESS DISORDER A. Exposure to death/injury/sexual assault from: Experience event Occurred to friend See event Repeat/extreme exposure B. Symptoms across 4 categories Intrusion Avoidance Mood/cognition Hyper-arousal C. Duration 3 to 30 days (a key item) D. Distress/impairment E. R/O substances, med Dx, brief psychosis, etc. AMSP 2018

  7. POSTTRAUMATIC STRESS DISORDER A. Exposure to death/injury/sexual assault from: Experience event Occurred to friend See event Repeated/extreme exposure B. 1+ intrusive symptoms (memories, dreams, etc) C. 1+ avoid thoughts/reminders of event D. 2+ (-) mood/thoughts re event (guilt/detached) E. 2+ arousal symptoms (↑ vigilance/startle, etc) F. Duration > 1 month (a key item) G. Distress/impairment H. R/O substances, med Dx, psychosis, etc. AMSP 2018

  8. Clinical Case: Steve Iraq – ambushed at dusk, comrades killed 6 months post-deployment, Withdrawn Anxious Nightmares Irritable Easily upset Feels guilty Refuses help: talking about trauma upsetting AMSP 2018

  9. PTSD Prevalence ~90% of US ever had traumatic event <20% traumatized  PTSD Depends on nature of the trauma ↑ for interpersonal trauma (e.g. rape) Lifetime PTSD in US ~10% AMSP 2018

  10. PTSD: Course Chronic; 1/3 still symptomatic after 10 years ↑ risk other psychiatric syndromes 50% have major depressive episodes* ~10% have panic attacks* *Those symptoms overlap with PTSD AMSP 2018

  11. PTSD Comorbidity ↑ medical problems vs general population: Neurologic: 2x Cardiovascular problems: 1.5x Respiratory problems: 2x Chronic fatigue syndrome: 6x Fibromyalgia: 2.5x AMSP 2018

  12. Update on Steve Anxiety & insomnia Chronic pain Isolated / depressed Drinks heavily to try to help sleep AMSP 2018

  13. Lecture Covers • Dx, prevalence & course of PTSD • Dx prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018

  14. Alcohol Intoxication • Recent drinking • Problematic behavior (e.g., aggression*) • 1+ of: slurred speech, ↓coordination, unsteady gait, nystagmus, ↓attention*/memory, stupor/coma D. R/O other med or mental probs as cause *can also occur in PTSD AMSP 2018

  15. Alcohol Withdrawal (W/D) A. Stopping alcohol after heavy, prolonged use B. 2+ of Autonomic hyperactivity Hand tremor Insomnia Nausea/vomiting Hallucinations Agitation Anxiety Seizures C. Cause impairment or distress D. R/O med/psych Dx or another substance AMSP 2018

  16. Alcohol Use Disorder Larger amounts used Much time spent Attempts cut down Neglecting major roles Important activities ↓ Interpersonal probs Physical/psych probs Hazardous use Craving 2+ of 11 symptoms (in same yr) Tolerance (defined by either) ↑ amounts for same effect ↓ effect with same amount Withdrawal (defined by either) Withdrawal syndrome Drink to ↓ withdrawal Lifetime risk8: ♂ 15%; ♀ 10% AMSP 2017

  17. Markers of Heavy Drinking Liver enzymes (for very heavy drinking) AST, ALT (aspartate & alanine aminotransferases) >500U/I associated with alcoholic hepatitis GGT (Gamma glutamyltransferase) Indicates heavy drinking Sensitivity and specificity ~75% CDT (carbohydrate deficient transferrin) ~ 5+ drinks /day for >2 weeks Heavy drinking: >2.6%CDT AMSP 2018

  18. AUD Dx and Severity: Screening AUDIT (Alcohol Use Disorder Identification Test) 10 items, 2-3min, score 0-40, 8+ = unhealthy use 70% sensitive, 80% specific for severe problems AUDIT-C (Consumption Questions) 3 questions scored 0-4 3+(F) and 4+(M) suggests unhealthy drinking CAGE (Cut down; Annoyed; Guilty; Eye-Opener) Answer “yes/no,” if >2 “yes” likely (+) AUD Best in medical, surgical settings, w/ blood tests AMSP 2018

  19. AUD Course (1) Intensity fluctuates Heavy drinking & problems Stop drinking Temporary control drinking 20% long term remission w/out Rx <10% can drink without problems AMSP 2018

  20. AUD Course (2) If drinking continues: ↓life ~15 years ↑ heart attacks and strokes ↑ cancer GI track/breast/head & neck, etc. Liver disease AMSP 2018

  21. Lecture Covers • Dx, prevalence & course of PTSD • Dx, prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018

  22. PTSD + AUD Co-morbidity If PTSD, 5x more likely to develop AUD Possible reasons for co-occurrence Trauma  AUD AUD  trauma PTSD, AUD w/d Sx can overlap AMSP 2018

  23. PTSD + AUD: Diagnosis If AUD, always assess* for PTSD If PTSD, always assess* for substance problems Assess for PTSD when patient Not intoxicated Not in withdrawal * Helpful tools are next AMSP 2018

  24. Clinician Administered PTSD Scale (CAPS) Requires formal training Gold standard Dx PTSD or track symptoms Structured clinical interview Scoring +/- PTSD Diagnosis Presence, severity, intensity of each sx Higher scores = greater severity AMSP 2018

  25. PTSD Checklist for DSM-5 (PCL-5) Self-report Diagnose or track symptoms 20 questions scored: “not at all – extremely” Scoring Range scores 0-80 > 33 suggests DSM-5 Dx Must have trauma and sx from DSM cluster AMSP 2018

  26. Steve Goes to VA 7:30AM clinic for pain eval: EtOH on breath AUDIT-C = 10, Referred to mental health Dx: Suspect PTSD, EtOH W/D Agrees to stay for observation Later: sweaty, tremors, pulse 130  detox AMSP 2018

  27. Lecture Covers • Dx prevalence & course PTSD • Dx prevalence & course AUD • Clinical issues for co-morbidity • Treatment AMSP 2018

  28. Treatment of PTSD + AUD Rx best if both Dxd and Rxd Cognitive behavioral therapies Medications effective More research needed AMSP 2018

  29. Rx PTSD: Psychotherapy Cognitive processing therapy (CPT) Pts view self, world negatively Goal: change how a person thinks Prolonged exposure (PE): Exposure → ↓ fear Goal: ↓ avoiding thoughts/places that → anxiety Eye movement desensitization & reprocessing Perform alternating eye movements Talk about memory with therapist AMSP 2018

  30. Rx PTSD: Meds Meds or therapy effective: combine if fail both Take as Rx’d Selective serotonin reuptake inhibitors (SSRIs) Rx PTSD, depression, anxiety 4-6 weeks to be effective Side effects: sexual, GI Prazosin (Minipress): Rx nightmares Side effect: lower BP when stand AMSP 2018

  31. Rx AUD: Psychotherapy Cognitive Behavior Rx Identify triggers Learn to handle temptations Motivational enhancement therapy Build motivation vs telling pts what to do Empathic approach Self-help Alcoholic Anonymous AKA “12-step” Spiritual framework AMSP 2018

  32. Rx AUD: Meds Naltrexone (Trexan, Vivitrol) ↓cravings, drink less if relapse Rx orally or monthly injection Disulfuram (Antabuse) Warn: if drink  sick Supervised dosing best Acamprosate (Campral) Helps prolong abstinence Side effects: nausea and diarrhea Not metabolized in liver AMSP 2018

  33. Treatment of co-morbid PTSD + AUD Psychotherapy Trauma Rx +SUD Rx Seeking Safety Individual or group Pharmacology AMSP 2018

  34. Rx Co-morbid PTSD + AUD Integrated Rx Historically thought must Rx SUD 1st SUD + PTSD Rx providers work as team Integrated Rx preferred Outcomes PTSD Sx ↓50% PTSD Rx does not → ↑ drinking Research needed AMSP 2018

  35. Steve’s Progress After detox, Dx AUD PCL-5 = 62, Dx PTSD Begin sertraline and naltrexone Continue PTSD-SUD Rx at VA on discharge Helps Rx team understands PTSD-drinking link AMSP 2018

  36. Lecture Covered Dx, prevalence & course of PTSD Dx, prevalence & course of AUD Clinical issues for co-morbidity Treatment AMSP 2018

  37. Takeaway Points PTSD + AUD commonly co-occur Co-occurring disorders is problematic Dx of both disorders is essential for Rx Combined Rx can be effective AMSP 2018

  38. References (1) 1. Resnick HS, Kilpatrick DG, Dansky BS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult ClinPsychol 1993; 61:984.  2. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52:1048.  3. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617. 4. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry 2015; 72:757. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013. 6. Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Fried-man MJ. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress 2013;26(5):537–47. 7. Sareen, Jitender, et al. “Physical and Mental Comorbidity, Disability, and Suicidal Behavior Associated With Posttraumatic Stress Disorder in a Large Community Sample.” Psychosomatic Medicine, vol. 69, no. 3, 2007, pp. 242–248. 8. Compton WM, Thomas YF, Stinson FS, Grant BF (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the national epidemiologic survey on alcohol and related conditions.Arch Gen Psychiatry, 64:566-76. 9. Schuckit, Marc A. Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment. Springer Science Business Media, Inc., 2006. 10. Conigrave, Katherine M., et al. “Traditional Markers of Excessive Alcohol Use.” Addiction, vol. 98, 2003 11. Galanter, Marc, et al. The American Psychiatric Publishing Textbook of Substance Abuse Treatment. American Psychiatric Association Publishing, 2015. 12. Miller, P. M., Dominick, C. S., & Anton, R. F., (2004).  Carbohydrate-deficient transferrin test: A tool for detecting alcohol abuse. Current Psychiatry,5(6), 80-87. 13. Bradley, Katharine A., et al. “AUDIT-C as a Brief Screen for Alcohol Misuse in Primary Care.” Alcoholism: Clinical and Experimental Research, vol. 31, no. 7, 2007, pp. 1208–1217 14. Schuckit, Marc A. “Alcohol-Use Disorders.” The Lancet, vol. 373, no. 9662, 2009, pp. 492–501. 15. Taylor, Mandrill, et al. “Treatment of Alcohol Use Disorder and Co-Occurring PTSD.” The American Journal of Drug and Alcohol Abuse, vol. 43, no. 4, 2016, pp. 391–401. 16. Khantzian EJ. Self-regulartion and self-medication factors in alcoholism and addictions. Similarities and differences. Recent Dev Alcohol 1990;8;255-271. 17. Ries, Richard, et al. The ASAM Principles of Addiction Medicine. Wolters Kluwer Health, 2014. 18. Jacobsen LK, Southwick SM, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. Am J Psychiatry 2001;158(8):1184-1190 AMSP 2018

  39. References (2) 19. “PTSD: National Center for PTSD.” Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) - PTSD: National Center for PTSD, 27 Jan. 2017.  20. “PTSD: National Center for PTSD.” Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID PTSD Module) - PTSD: National Center for PTSD, 5 July 2007. 21. “PTSD: National Center for PTSD.” PTSD Checklist for DSM-5 (PCL-5) - PTSD: National Center for PTSD, 11 May 2017.  22. Ponniah, Kathryn, and Steven D. Hollon. “Empirically Supported Psychological Treatments for Adult Acute Stress Disorder and Posttraumatic Stress Disorder: a Review.” Depression and Anxiety, vol. 26, no. 12, 2009, pp. 1086–1109 23. PTSD: National Center for PTSD.” Eye Movement Desensitization and Reprocessing (EMDR) for PTSD - PTSD: National Center for PTSD, 19 Aug. 2016, www.ptsd.va.gov/public/treatment/therapy-med/emdr-for-ptsd.asp. 24. Lancaster, Cynthia, et al. “Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment.” Journal of Clinical Medicine, vol. 5, no. 11, 2016, p. 105. 25. Stein, Murray B. “Pharmacotherapy for Posttraumatic Stress Disorder in Adults.” Edited by Peter P Roy-Byrne and Richard Hermann, UpToDate, 3 Feb. 2017, www.uptodate.com/contents/pharmacotherapy-for-posttraumatic-stress-disorder-in-adults. 26. Khachatryan, Davit, et al. “Prazosin for Treating Sleep Disturbances in Adults with Posttraumatic Stress Disorder: a Systematic Review and Meta-Analysis of Randomized Controlled Trials.” General Hospital Psychiatry, vol. 39, 2016, pp. 46–52. 27. Raskind, Murray A., et al. “Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans.” New England Journal of Medicine, vol. 378, no. 6, 2018, pp. 507–517. 28. Galanter, Marc, and Herbert D. Kleber. Psychotherapy for the Treatment of Substance Abuse. American Psychiatric Pub., 2011. 29. Winslow, Bradford T., et al. “Medications for Alcohol Use Disorder.” American Family Physician, 15 Mar. 2016. 30. Laaksonen, E., et al. “A Randomized, Multicentre, Open-Label, Comparative Trial of Disulfiram, Naltrexone and Acamprosate in the Treatment of Alcohol Dependence.”Alcohol and Alcoholism, vol. 43, no. 1, 2007, pp. 53–61 31. Roberts, Neil P., et al. “Psychological Interventions for Post-Traumatic Stress Disorder and Comorbid Substance Use Disorder: A Systematic Review and Meta-Analysis.” Clinical Psychology Review, vol. 38, 2015, pp. 25–38 32. Najavits, Lisa M. Seeking Safety: a Treatment Manual for PTSD and Substance Abuse. The Guilford Press, 2003. 33. Petrakis, Ismene L., and Tracy L. Simpson. “Posttraumatic Stress Disorder and Alcohol Use Disorder: A Critical Review of Pharmacologic Treatments.” Alcoholism: Clinical and Experimental Research, vol. 41, no. 2, 2017, pp. 226–237 34. Brady, Kathleen T., et al. “Sertraline in the Treatment of Co-Occurring Alcohol Dependence and Posttraumatic Stress Disorder.” Alcoholism: Clinical & Experimental Research, vol. 29, no. 3, 2005, pp. 395–401. 35. Avery, Jonathan D., and John W. Barnhill. Co-Occurring Mental Illness and Substance Use Disorders: a Guide to Diagnosis and Treatment. American Psychiatric Association Publishing, 2018. 36. Back, Sudie E., et al. “Symptom Improvement in Co-Occurring PTSD and Alcohol Dependence.” The Journal of Nervous and Mental Disease, vol. 194, no. 9, 2006, pp. 690–696. 37. Coffey, Scott F., et al. “Trauma-Focused Exposure Therapy for Chronic Posttraumatic Stress Disorder in Alcohol and Drug Dependent Patients: A Randomized Controlled Trial.”Psychology of Addictive Behaviors, vol. 30, no. 7, 2016, pp. 778–790. AMSP 2018

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