J. Concurrent PTSD and Substance Abuse

OBJECTIVE

Improve management of PTSD symptoms when they are complicated by a concurrent substance abuse problem.

BACKGROUND

Research has documented a strong relationship between PTSD and substance abuse problems in civilian and military populations of both genders (e.g., NVVRS; Kessler et al., 1995). For example, among male veterans seeking treatment for combat-related PTSD, high rates of lifetime alcohol use disorders and drug abuse/dependence have been documented (Roszell et al., 1991). Similarly, an extensive literature has documented high rates of PTSD among male veterans seeking substance abuse treatment. For example, Triffleman et al. (1995) found that 40 percent of substance abuse inpatient veterans had a lifetime history of combat-related PTSD, 58 percent had a lifetime history of PTSD due to combat or other traumatic exposure, and 38 percent had current PTSD.

A prospective and retrospective study (Breslau et al., 2003) reported an increased risk for the onset of nicotine dependence and drug abuse or dependence in persons with PTSD, but no increased risk or a significantly (P = .004) lower risk (for nicotine dependence, in the prospective data) in persons exposed to trauma in the absence of PTSD, compared with unexposed persons. Exposure to trauma in either the presence or the absence of PTSD did not predict alcohol abuse or dependence.

Clinicians should note that substance abuse may mask or suppress PTSD symptoms, causing an individual to apparently fail to meet criteria for PTSD diagnosis.

RECOMMENDATIONS

1. Substance use patterns of clients with trauma histories or PTSD should be routinely assessed (see the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders).
2. Substance abusers should be routinely screened for trauma exposure and PTSD.
3. Integrated PTSD-Substance Abuse Treatment should be considered.
4. Substance-abusing patients with PTSD should be educated about the relationships between PTSD and substance abuse, referred for concurrent PTSD treatment, or provided with integrated PTSD/Substance Abuse treatment.
5. Substance Abuse-PTSD patients should receive follow-up care that includes a continued focus on PTSD issues.

DISCUSSION

Substance abusers with PTSD experience higher levels of subjective distress and other problems than substance abusers without PTSD. For instance, compared with women who abuse substances but do not meet diagnostic criteria for PTSD, female PTSD-substance abusers report greater psychopathology, substance abuse problems, dissociation, and behaviors associated with borderline personality disorder (e.g., Ouimette et al., 1996). Patients with concurrent PTSD and substance abuse may benefit less from conventional substance abuse treatment than those with substance abuse only (Ouimette et al., 1998a), and PTSD is frequently under-diagnosed among individuals receiving treatment for substance abuse (Dansky et al., 1997). These considerations have led some authorities to develop specialized treatments that integrate treatment for PTSD and substance abuse (Najavits, 2002; Triffleman et al., 1999).

Therapies that integrate treatment for PTSD and substance abuse are now being developed and evaluated. The most studied approach is the “Seeking Safety” treatment that is available in manualized form (Najavits, 2002), has preliminary evidence of effectiveness for both substance abuse and PTSD, and is being evaluated in RCTs. This latter treatment is an “early treatment” or “first stage” present-centered therapy for substance use and PTSD that is organized around issues of safety and self-care; it does not promote exploration of trauma histories via narrative accounts or exposure treatment. It is a 25-session treatment that teaches trauma- and substance abuse-related behavioral (e.g., emotional “grounding”), cognitive (e.g., getting out of “user thinking” and “victim thinking”), and interpersonal (e.g., self-protection in relationships) coping skills.

More generally, because substance abusers with PTSD may be at higher risk for relapse and their relapses may be “triggered” in part by trauma reminders and cues, clinicians should adapt relapse prevention methods to help substance abuse patients identify their trauma-related relapse cues and prepare them to cope with those triggers without drinking or using.

Because withdrawal symptoms experienced during early abstinence may be associated with a resurgence of traumatic memories, worsening PTSD symptoms, and, possibly, increased risk for suicidal thoughts or attempts (Kosten & Krystal, 1988), the client should be supported closely through this period, prepared for possible short-term worsening of PTSD symptoms, and helped to develop strategies for managing symptoms and urges to drink or use.

12-step programs can play an important role in the treatment of PTSD/substance abuse. In PTSD/substance abuse veterans hospitalized for substance abuse disorder, greater 12-step involvement was associated with a number of positive changes during treatment (Ouimette et al., 1998b) and with remission from substance abuse/dependence over a two-year period. Involvement in 12-Step groups may be especially helpful for patients who are socially isolated, lack positive social activities and social support, or lack a social group supportive of abstinence. It is possible that PTSD patients may have special difficulties in affiliating with the groups (e.g., social anxiety, social skills deficits, difficulties with intimacy and trust, feeling unsafe in groups of people) and it may be appropriate in some circumstances for clinicians to target affiliation as a treatment goal. With regard to women, consideration should be given to the fact that exposure to 12-step environments comprised largely of men may present a real problem for those with a history of male-perpetrated sexual assault; use of women’s meetings may be preferable, especially early in recovery.

Although little is known about the management of substance abuse in the context of acute stress reactions, one RCT has demonstrated that brief intervention with those admitted to the hospital for injury can reduce alcohol consumption and injury recidivism (Gentilello et al., 1999).