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Post-Traumatic Stress Disorder (PTSD) & Alcohol Use Disorder (AUD). J. David Stiffler, MD Department of Psychiatry New York University School of Medicine. PTSD and AUD. Are both common PTSD lifetime ~ 10% AUD lifetime ~ 12% Having PTSD or AUD ↑s risk of the other
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Post-Traumatic Stress Disorder (PTSD) & Alcohol Use Disorder (AUD) J. David Stiffler, MD Department of Psychiatry New York University School of Medicine AMSP 2018
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
Lecture Covers • Dx, prevalence & course of PTSD • Dx, prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018
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
Lecture Covers • Dx, prevalence & course of PTSD • Dx, prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018
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
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
Clinical Case: Steve Iraq – ambushed at dusk, comrades killed 6 months post-deployment, Withdrawn Anxious Nightmares Irritable Easily upset Feels guilty Refuses help: talking about trauma upsetting AMSP 2018
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
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
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
Update on Steve Anxiety & insomnia Chronic pain Isolated / depressed Drinks heavily to try to help sleep AMSP 2018
Lecture Covers • Dx, prevalence & course of PTSD • Dx prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018
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
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
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
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
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
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
AUD Course (2) If drinking continues: ↓life ~15 years ↑ heart attacks and strokes ↑ cancer GI track/breast/head & neck, etc. Liver disease AMSP 2018
Lecture Covers • Dx, prevalence & course of PTSD • Dx, prevalence & course of AUD • Clinical issues for co-morbidity • Treatment AMSP 2018
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
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
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
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
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
Lecture Covers • Dx prevalence & course PTSD • Dx prevalence & course AUD • Clinical issues for co-morbidity • Treatment AMSP 2018
Treatment of PTSD + AUD Rx best if both Dxd and Rxd Cognitive behavioral therapies Medications effective More research needed AMSP 2018
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
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
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
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
Treatment of co-morbid PTSD + AUD Psychotherapy Trauma Rx +SUD Rx Seeking Safety Individual or group Pharmacology AMSP 2018
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
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
Lecture Covered Dx, prevalence & course of PTSD Dx, prevalence & course of AUD Clinical issues for co-morbidity Treatment AMSP 2018
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
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