Post-traumatic Stress Disorder and Alcohol Use Disorder

J. David Stiffler, MD

Alcohol Medical Scholars Program



I. Introduction (SLIDE 2)

    A. Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are common

        1. US lifetime prevalence PTSD ~ 10%1,2,3       

        2. Lifetime prevalence AUDs = 12%4

    B. Having a dx of PTSD or AUD

        1. Makes the development of the other dx more likely

        2. And having both dx can make accurate dx difficult

    C. Treatment for each can be can be effective

    D. Therefore, this lecture will cover (SLIDE 3)

        1. Diagnosis, prevalence and course of PTSD

        2. Diagnosis, prevalence and course of AUD

        3. Clinical issues related to PTSD + AUD co-morbidity

        4. Treatment of PTSD + AUD individually and together


Clinical Case (SLIDE 4)


II. Dx, prevalence, course: first acute stress disorder and then PTSD (SLIDE 5)

    A. Diagnostic and Statistical Manual of Mental Disorders (DSM) Dx of acute stress disorder (ASD)5 (SLIDE 6)

        1. Traumatic event with symptoms of PTSD (detailed below)

        2. Symptoms cause distress and impairment

        3. Duration < 1 month (key difference from PTSD)

    B. DSM definition of PTSD5 (SLIDE 7)

        1. Traumatic event defined by 1+ of the following (event is required for diagnosis)

            a. Exposure to actual or threatened death, serious injury, or sexual violence

            b. Experiencing or witnessing event

            c. Learning event occurred to a close relative or friend

            d. Experiencing repeated or extreme exposure to aversive details of event

        2. Intrusion: 1+ of following

            a. Involuntary, distressing memories

            b. Distressing dreams

            c. Dissociative (feeling unreal) reactions or flashbacks

                1’ Feeling or acting as if trauma recurring

                2’ Not same as thinking about or dreaming about trauma

                3’ Occurs on severity continuum

           d. Psychological distress at exposure to trauma cues (e.g., loud noises)

           e. Physiological reactions to internal or external cues

                1’ Racing heartbeat

                2’ Dizziness

        3. Avoidance of or efforts to avoid: 1+ of following

            a. Thinking of distressing memories, thoughts, feelings

            b. External reminders of the trauma

                1’ People, conversations about the trauma

                2’ Situations, activities that remind of trauma

        4. Cognitive/mood symptoms: 2+ of following

            a. Inability to remember part of traumatic event

            a. Negative beliefs about oneself, others, or the world

            b. Distorted thoughts about cause or consequences of traumatic event

            c. Persistent negative emotional state (e.g., guilt)

           d. ↓↓interest or participation in significant activities

           e. Feeling detached from others

            f. Inability to experience positive emotions like:

                1’ Happiness

                2’ Love

        5. Hyper-arousal (e.g., constant scanning for problems): 2+ of following

            a. Irritable behavior + angry outbursts

            b. Reckless or self-destructive behavior like:

                1’ Dangerous driving

                2’ Self harm behaviors; superficial cutting of one’s arms, etc.

            c. Hypervigilance

                1’ Scanning the room for danger in safe situations

                2’ Unrealistic fear of heart attack

            d. ↑↑ startle response

            e. concentration

            f. Sleep disturbances

        6. Duration of symptoms > 1month

        7. Symptoms distress and impairment

        8. Disturbance not due to substance use or medical condition (e.g., panic disorder)


Clinical Case (Slide 8)   


C. Prevalence PTSD (SLIDE 9)

        1. ~90% of US ever had a lifetime traumatic event6

        2. <20% traumatized à PTSD5

            a. Depends on the nature of the trauma

            b. Higher rates for interpersonal trauma

                1’ Rape, intimate partner violence    

                2’ Assault

        3. Lifetime PTSD in US ~10%1,2,3   

      D. Course of PTSD (SLIDE 10)

            1. Chronic condition; 1/3 still symptomatic after 10 years2

            2. ↑ risk other psychiatric syndromes2 

                a. ~50% have major depressive episodes – symptom overlap with PTSD

                b. ~ 10% have panic attacks – symptom overlap with PTSD

            3. ↑ likelihood medical problems vs general population for:7 (SLIDE 11)

                a. Neurologic (stroke, epilepsy): 2x

                b. Cardiovascular problems (hypertension, heart disease): 1.5x

                c. Respiratory problems (asthma, chronic bronchitis, emphysema): 2.5x

                d. Chronic fatigue syndrome (fatigue, headaches, ↓concentration): 6x

                e. Fibromyalgia (widespread pain, fatigue): 2.5x


Clinical Case (Slide 12)


III. Dx, prevalence, course: AUDs (SLIDE 13)

    A. DSM definition of alcohol intoxication; all of (SLIDE 14)

        1. Recent ingestion

        2. Significant behavioral or psychological changes after use like:

            a. Aggressive behavior (*also occurs with PTSD)

            b. Mood changes

            c. Impaired judgment

        3. After use, 1+ of the following

            a. Slurring

            b. Incoordination

            c. Poor balance

            d. Nystagmus: repetitive involuntary eye movements

            e. Impaired attention or memory (*also occurs in PTSD)

            f. Near-unconsciousness or coma

        4. Symptoms not due to medical or psychiatric condition or another substance

     B. DSM definition of withdrawal (SLIDE 15)

        1. Stopping alcohol use after heavy, prolonged use

        2. 2+ of the following:

            a. Autonomic hyperactivity like:

                1’ Sweating

                2’ Racing heartbeat

            b. Hand tremor

            c. Insomnia

            d. Nausea or vomiting

            e. Hallucinations; unreal sensations generated in the mind (seen only in EtOH delirium)

            f. Agitation

            g. Anxiety

            h. Seizures

        3. Symptoms cause impairment or distress

        4. Symptoms not due to another medical, psychiatric condition or another substance

    C. DSM definition of AUD (SLIDE 16)

            1. 2+ within same 12 months

            2. Including:

                a. Drinking more or for longer than intended

                b. Unsuccessful efforts to ↓ or stop

                c. Spending a large amount of time drinking or recovering from effects

                d. Craving (i.e., strong desire/urge) for alcohol

                e. Drinking → failure to fulfill life obligations (e.g., missing work)

                f. Drinking → giving up important activities (e.g., exercise/ family birthday parties/etc.)

                g. Drinking in hazardous situations (e.g., while or before driving)

                h. Continued drinking despite social/interpersonal problems

                i. Continued drinking despite physical/psychological problems

                j. Tolerance (e.g., needing to drink ↑ to get same effect)

                k. Withdrawal symptoms (i.e., or stop > day of hands shaking/nausea

   D. Prevalence of AUD8

        1. Lifetime risk for men = ~ 15%

        2. Lifetime risk for women = ~ 10%

    E. Biologic markers of heavy drinking (SLIDE 17)

        1. Liver enzymes; AST, ALT (aspartate aminotransferase, alanine aminotransferase)

            a. Indicate liver cell damage of any cause à not EtOH sensitive or specific9

             b. AST:ALT >2:1 indicates alcohol related disease10

             c. AST or ALT >500U/I associated with alcoholic hepatitis (liver inflammation)10

          2. GGT (Gamma glutamyltransferase)9

              a. Indicates heavy drinking (eg. ~5+ drinks/day repeatedly)

              b. EtOH problem sensitivity and specificity ~75%

               c. May not be good relapse measure11

            3. CDT (carbohydrate deficient transferrin)12

                a. Indicates ~ 5+ drinks /day for >2 weeks

                b. Heavy drinking indicated by >2.6%CDT

                c. Can be used to monitor abstinence

    F. AUD Dx and severity measures (SLIDE 18)

          1. Screening questionnaires

              a. AUDIT (Alcohol Use Disorder Identification Test)9

                  1’. 10 questions

                  2’ Takes 2-3min

                  3’ Score 0-40 à risk level

                  4’ 8+ = unhealthy alcohol use

                  5’ 70% sensitivity, 80% specificity for severe problems

              b. AUDIT-C (Alcohol Use Disorder Identification Test-Consumption Questions)13

                  1’ 3 consumptions questions from AUDIT; briefer

                  2’ Each question scored 0-4 points

                  3’ Total score determines +/- for unhealthy drinking

                      a’ 4+ = (+) men

                      b’ 3+ = (+) women

            c. CAGE

                  1’ Cut down; Annoyed; Guilty; Eye-Opener (each as yes or no)

                  2’ >2 (+) responses indicate likely AUD

                  3’ Best used in medical, surgical settings and with blood tests14

    G. AUD course (SLIDE 19)

       1. Intensity fluctuates9

           a. Heavy drinking & problems

           b. Stop drinking (happens to almost all at times, i.e. after crisis)

           c. Temporary control drinking

          e. 20% long term remission without treatment

          f. <10% able to drink without problems

       2. If continues:9 (SLIDE 20)

           a. life ~15 years

           b. heart attacks and strokes

           c. cancer GI track/breast/head & neck, etc.

           d. Liver disease (~80% do not have cirrhosis)14


IV. PTSD + AUD co-morbidity (SLIDE 21)

    A.  Prevalence (SLIDE 22)

        1. PTSD + AUD co-morbidity

            a. If PTSD, 5x more likely to develop AUD15

            b. Shows importance of screening for both disorders together

    B. Etiology of co-morbid Dx

        1. Trauma/PTSD might à AUD

            a. Self-medication hypothesis: using a substance to reduce PTSD symptoms16

            b. For example, drinking to sleep or numb emotions

        2. AUD might à PTSD17, 18

            a. Heavy drinking (HD) can accidents and trauma: trauma required for PTSD

            b. HD →↑anxiety which could intensity reaction to stress

    C. Some PTSD and alcohol withdrawal symptoms cross over5

            a. Insomnia

            b. Anxiety, agitation in EtOH w/d can look like hyperarousal and reactivity in PTSD

            c. Sweating/ ↑HR seen in both

            d. Overlap in symptoms can make accurate dx difficult


V. Making the diagnosis of PTSD + AUD (SLIDE 23)

A.      General principles17

        1. If AUD, always assess for PTSD; if PTSD, always assess for alcohol/drug problems

        2. Assess for PTSD when no intoxicated, nor in w/d

    B. PTSD Dx and severity measures:

        1. Clinician Administered PTSD Scale (CAPS)19,20 (SLIDE 24)

            a. Requires formal training to administer

            b. Gold standard for severity and Dx

            c. Used to diagnose current or lifetime PTSD or track symptoms over time

            d. Structured clinical interview

                   1’ Assess 30 areas for each DSM symptom

                   2’ Takes 45-60 min to administer

            e. Scoring

                  1’ +/- PTSD Diagnosis

                  2’ Presence, severity, intensity of each sx graded 0-4 (absent – extreme)

                  3’ Higher scores = greater severity

        2. PTSD Checklist for DSM-5 (PCL-5)21 (SLIDE 25)

            a. Self-report

            b. To diagnose or track symptoms

            c. 20 questions scored 0-4 (“not at all” – “extremely”)

            d. Scoring

                 1’ Range 0-80 from low to highest possible score

                 2’ > 33 suggests provisional DSM-5 diagnosis (PTSD 2017)

                 3’ Must have trauma and sx from each of 4 DSM clusters defined above

                       a’ Intrusion

                       b’ Avoidance

                       c’ Changes in cognition/mood

                       d’ Hyperarousal


Clinical Case (Slide 26)


VI. Treatment (SLIDE 27)

     A. Treatment of each is best if both Dx are Rx at the same time: (SLIDE 28)

          1. Cognitive behavioral therapies that focus on difficult thoughts, feelings, behaviors

          2. Medications that have been shown to be better than placebo in double blind research

          3. More research is needed because each Dx has:

                a. Spontaneous remissions (cannot evaluate Rx effects without controls)

                b. Intensity fluctuates over time (cannot evaluate Rx effects without controls)

                c. Result is most open trials look positive when controlled do not

          4. Lecture to present Rx PTSD, then Rx AUD, then combined Rx

     B. Treatment of PTSD

          1. Psychotherapies are crucial22 (SLIDE 29)

               a. Specific therapies for PTSD are called “Trauma Focused Therapies”

               b. Therapies with double blind study support (aka EBPs = evidence-based practices)

               c. Examples of trauma focused psychotherapies

                   1’ Cognitive processing therapy (aka “CPT”)

                       a’ PTSD pts tend to view themselves, the world and other people negatively

          b’ Basic approach is to change how a person thinks

                       c’ For example:

                          1’’ Learning to not blame yourself for the bad things that occurred

                          2’’ Learning to trust other people again

                   2’ Prolonged exposure (aka “PE”)

                       a’ Goal: patients stop avoiding thoughts/places that anxiety

                       b’ Exposure to uncomfortable situations → ↓, fear

                           1’’ Like diving into a cold pool and adjusting to temperature

                            2’’ Or feeling less nervous after giving many presentations  

          c’ For example:

                            1’’ Repeatedly ride subway to tolerate loud noise and crowds

                             2’’ Imagine difficult memories so they are no longer upsetting

               3’ Eye movement therapy22,23

                   a’ Formerly called Eye-Movement Desensitization and Reprocessing (aka “EMDR”)

                   b’ Basic approach is to talk through bad memories with a therapist

                   c’ Moving eyes back and forth while talking helps go through memory

                   d’ Neurologic mechanism is unclear and controversial

                   e’ Result is memories become less disturbing

     2. Medications shown to be helpful for Rx PTSD (SLIDE 30)24,25

          a. Medications and psychotherapy effective: can combine meds + therapy if failed both Rx individually

          b. Must warn patient of med side effects and need to take exactly as Rxd

          c. Selective serotonin reuptake inhibitors (SSRI)

               1’ Can ↓PTSD symptoms, depression and anxiety

               2’ Medication often take 4-6 weeks to be effective

              3’ Symptoms can come back when medication is stopped

               4’ Adjust dose based on response and side effects

               5’ Side effects can include

                    a’’ Sexual side effects (e.g. cannot achieve orgasm)

                    b” Sedation

                    c’’ GI symptoms (e.g., nausea, diarrhea)

               6’ Example is sertraline (Zoloft) 50-200mg/day

          d. Prazosin (Minipress) (e.g., 6mg at bedtime): reduces activation of the fight/flight system26

              1’ Can reduce nightmares and improve overall sleep quality

             2’ However, was not superior to placebo in recent randomized controlled trial27

              3’ A side effect: BP drop when they stand up

   C. Treatment of AUD

        1. Individual psychotherapies (SLIDE 31)

            a. Cognitive behavioral therapy to learn:28

                1’ What triggers their drinking. For example

                   a’ Being around friends or family who drink

                   b’ Negative feelings like being rejected by a partner or feeling like a failure

                2’ How to handle situations where are tempted to drink. For example

                    a’ Making sure they have a realistic plan to confidently refuse EtOH

                    b’ Learning ways to cope with difficult feelings like exercise

            b. Motivational enhancement therapy27

                1’ People more likely to change what they want to vs being told what to do

                2’ Approach helps patients self-motivation to stop drinking

                3’ Important to be empathic, respectful and not show frustration with patient

        2. Self Help groups like Alcoholics Anonymous9

            a. AKA “12-step” program because are 12 recovery steps

            b. Offers support 24 hours/day, 7 days per week

            c. A spiritual framework where a “Higher Power” is identified

                  1’ Higher power does not have to be “God”

                  2’ Can be a meaningful to patient, like “humanity” or “love”

                  3’ Not all patients accept this step, but may still benefit from AA

     3. Medications29 (SLIDE 32)

            a. Naltrexone (Trexan, Vivitrol): medication that blocks opiate receptors

                  1’ cravings for EtOH

                  2’ If relapse, tend to drink less

                  3’ Rx orally (50mg/day) or as a monthly injection

            b. Disulfuram (Antabuse)

                   1’ Blocks alcohol metabolism at acetaldehyde (metabolite)

                   2’ Drinking on disulfiram → nausea and vomiting

                   3’ Can’t give if patient has heart disease, diabetes, etc

                  4’ Critically important to warn to avoid EtOH in any form, i.e. common foods

                   5’ fear of effect of drinking; so hard to know if better than placebo

                   6’ A barrier to effectiveness is that people stop taking it

                   7’ Better outcomes with supervised dosing30

            c. Acamprosate (Campral)

                  1’ Helps patients remain abstinent longer

                  2’ Side effects include nausea and diarrhea

                 3’ Drug not metabolized in liver

                  4’ Common dose is 666mg 3x daily

                  5’ Three times a day dosing can compliance         

    D. Treatment of co-morbid PTSD + AUD (SLIDE 33)

        1. Psychotherapy

            a. Individual trauma focused Rx + SUD Rx can reduce PTSD symptoms and alcohol use31

            b. Seeking Safety is an integrated CBT based treatment for PTSD + SUD32

                1’ Consists of 25 topics that can be covered in any order. For example:

                      a’ Safety planning (i.e. reducing suicidality)   

                      b’ Behavior changes (i.e. improving self-care, getting enough sleep)

                      c’ Case management (i.e. career counseling)

               2’ Can be delivered in group or individual sessions

        2. Pharmacology

            a. No clear evidence that single medication can be used to treat both dx33

            b. Medications to treat each disorder can be used together safely33

            c. Sertraline (Zoloft) SSRI potentially → ↓drinking if PTSD preceded AUD34

        3. Integrated treatment (SLIDE 34)

            a. Historically thought that SUD had to be treated before PTSD31

            b. SUD and PTSD treatment providers work as a team

            c. Both dx can be treated simultaneously without either worsening33

            d. Many patients prefer integrated treatment36

        4. Outcomes37

            a. PTSD treatments can reduce PTSD symptoms by ~50% in patients with both dx

            b. PTSD Rx does not → ↑ drinking

            c. More research is needed in this area


Clinical Case (SLIDE 35)


VII. Conclusions (SLIDE 36, 37)

    A. PTSD + AUD commonly co-occur

    B. Co-occurring disorders is problematic

    C. Diagnosis of both disorders is essential for treatment

    D. Combined treatment can be effective




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