Alcoholism and Posttraumatic Stress Disorder
Joe E. Thornton, M.D.
Alcohol Medical Scholars Program
April 7, 2003
A. This lecture is important because:
1. Alcoholism and Posttraumatic Stress Disorder (PTSD) are both common
2. The symptoms from one can mimic the other
3. Co-occurring syndromes make each clinical picture more severe
4. Most physicians know little about either
The clinicianís dilemma is that people may increase their alcohol use in response to trauma,
Alcoholism can temporarily mimic PTSD
Alcoholism makes preexisting disorders (including PTSD) worse
B. This lecture will cover :
1. Clinical Information on Alcoholism
2. Clinical Information on PTSD
3. Strategies for diagnoses and treatment
4. Strategies for primary care treatment interventions
II. Background ñ Alcohol
1. Alcohol use described as a spectrum (1)
b. Non problem use
c. At-risk use
2. Alcoholism refers to Alcohol Use Disorders (2)
3. DSMIV Alcohol Use Disorders include both abuse and dependence
4. Dependence: 3 + of
c. Larger amounts/ longer use
d. Loss of control / unable to cut down on use
e. Significant time spent on thinking or obtaining alcohol
f. Reduced social functioning
g. Continued use despite negative consequences
5. Alcohol Abuse: 1+ of
a. Failure to fulfill major role obligations
b. Physically hazardous use
c. Legal problems related to use
d. Interpersonal problems related to use
B. Lifetime Prevalence (2)
a. Men 12.5 %
b. Women 6.4 %
a. Men 20.1%
b. Women 8.2 %
C. Clinical Course (3,4)
1. Following list is general picture; picture differs for any individual
2. Early course and milestones similar to general population, e.g.:
a. First drink ~ age 13
b. First intoxication ~ age 16
c. First problem ~ 21;
40% of all drinkers have some minor problem at some time
3. Dependence ~age 28
10% after age of 40, less than 10% before age 20
4. Variable course
a. Frequent periods of abstinence
Any given month ~50 % of alcoholics are abstinent
b. Spontaneous remissions ~ 20%
a. Dependence cuts 15 years off the life span
b. Deaths from heart disease, cancer, accidents, suicide
6. Psychiatric symptoms are prominent
a. Almost 100% have insomnia and bad dreams
b. Major temporary syndromes such as depression occur
c. Such symptoms occur in active alcoholism, disappear
d. Some alcohol related symptoms overlap with PTSD symptoms, e.g. insomnia, bad dreams, decreased participation in activities, abnormal affect, irritability, difficulty concentrating
III. Background : PTSD (5,6)
1. DSM-IV Posttraumatic stress disorder
2. History of traumatic event
a. Person experienced, witnessed, or was confronted with a disturbing event.
b. Response was intense fear, helplessness or horror
3. Event re-experienced as 1 + of
a. Intrusive recall
b. Recurrent distressing dreams
c. Acting or feeling as if the event were recurring
d. Intense distress at cues of the events
e. Physiologic reactivity on exposure to cues
4. Persistent avoidance of cues associated with the trauma and numbing of responsiveness as indicated by 3 + of
a. Efforts to avoid thoughts related to events
b. Efforts to avoid cues of the trauma
c. Inability to recall important aspects
d. Diminished interest or participation in activities
e. Estrangement (alienated from family, friends)
f. Restricted range of affect
g. Foreshortened sense of future
5. Increased arousal as evidenced by 2 +
a. Difficulty falling asleep or staying asleep
c. Difficulty concentrating
e. Exaggerated startle response
6. Duration of symptoms greater than 1 month
7. Symptoms cause distress and impairment
B. Lifetime prevalence (7,8)
1. ~70% of persons in US exposed to 1+ trauma
2. ~10% of trauma-exposed persons develop PTSD
3. Lifetime prevalence of PTSD:
a. Men ñ 5%
b. Women ñ 10%
C. Clinical Course ( 9,10)
1. Following list is general picture; picture differs for any individual
2. Risks for development of symptoms following trauma are associated with:
a. Severity of trauma
b. Prior Trauma
c. Prior psychiatric history
d. Peritraumatic dissociation (mentally separating from the event when it occurs)
e. Acute stress symptoms
f. Autonomic hyperarousal (flushing, pupillary dilation, bowel and bladder activity)
3. Variable course
a. Generally follows Acute Stress Disorder
b. Spontaneous remission is uncommon
4. Physical symptoms (11)
a. Common complaints include headache, gastrointestinal complaints, chest pain, dizziness, other non-specific somatic symptoms
b. No definitive link with physical health or mortality
5. Alcohol Use Disorders are common with PTSD (12)
Alcohol use and intoxication increase emotional numbing, social isolation, irritability
IV. Epidemiology: Alcohol Dependence and PTSD Co-occur
A. Patients with PTSD had lifetime rates of alcoholism 2-3x that of community samples (7,10,12)
B. Patients seeking treatment for alcoholism of PTSD 3x that of community samples
C. Substance-dependent adolescents inpatients have 5x community rate for PTSD (13, 14)
D. Inpatient alcohol-dependent women have 5x of PTSD (15)
V. However, PTSD and alcohol dependence symptoms overlap (15,16)
A. Increased arousal seen during both alcohol withdrawal and PTSD
3. Difficulty concentrating
B. Symptoms of avoidance, emotional numbing, associated with PTSD, alcohol intoxication, or alcohol induced cognitive disorders
1. Poor recall
2. Difficulty concentrating
3. Decreased interest or participation in activities
4. Emotional blunting
VI. Diagnostic strategies to see if PTSD is independent in an alcohol- dependent person (2)
A. Establish age of onset of alcohol dependence
B. Establish periods of abstinence since onset of dependence
C. Establish age of trauma and onset of PTSD
D. See if PTSD existed before alcohol dependence or during 3+ months of abstinence
E. Findings of dictate optimal treatment.
VII. General treatment for alcohol use disorders (17,18)
A. As with most chronic disorders, treatment is mostly cognitive/behavioral (19)
1. Increase motivation for abstinence.
2. Help rebuild life functioning.
3. Relapse prevention.
B. Intense treatment given for 2-4 weeks; then less intense for 6+ months
C. Self-help groups can be important.
D. Limited role for medications (20)
1. Naltrexone, 50 -150mg/d, slightly better than placebo.
2. Acamprosate, 2gm/d slightly better than placebo.
3. Little support for disulfiram, 250mg/d
4. No role for lithium, antidepressants, benzodiazepines (after detoxification is done), antipsychotics, etc.
VIII. Treatment of PTSD
A. Cognitive /behavioral therapies
1. Exposure Therapy (21)
a. Patient confronts the feared object or event with guided help from therapist.
b. Patient educated about common reactions to trauma
c. Patient is trained in behavioral symptom management
e.g. breathing retraining
d. Patient exposed by a number of techniques to the traumatic event and progressively masters the symptom response
2. Stress Inoculation Training
a. Therapist helps the patient to learn to manage the s symptoms of anxiety
b. Review of traumatic event or thoughts of the event not necessary
c. Effectiveness is greater than no treatment but may be less effective than Exposure Therapy
B. Eye Movement Desensitization and Reprocessing (EMDR) (22)
1. Wide use but still controversial, due to differences over the true value of the eye movements as the key component of 2. Patient reviews trauma(s) with therapist
3. Aversive experience evaluated
4. Cognitive schemas (interpretation) re-evaulated
5. Patient trained in lateral eye movements while focusing on traumatic responses.
C. Medications (23)
1. SSRI Antidepressants, e.g. sertraline 100mg/d
2. Other antidepressants, venlafaxine 225mg/d
3. Anxiolytics, second line medication, clonazepam 2mg/d
Note: Short term use only, be aware of any concurrent alcohol use, be aware of any history of substance abuse or dependence, be aware of potential for benzodiazepine abuse
4. Mood stabilizers, second line medication, divalproex 1500mg/d
5. Atypical antipsychotics, third line, olanzapine 10mg/d
IX. Treatment of Co-occurring PTSD and Alcohol Use Disorders
A. Wait and Treat Strategies (2).
1. Achieve abstinence and monitor PTSD symptoms
2. Control PTSD symptoms and monitor craving
B. Sequential treatment
1. Treat the most disabling syndrome first
2. If second syndrome still present after time then treat
C. Comprehensive Treatment (24, 25)
1. Coordinated treatments- alcohol counselors communicate with therapists treating PTSD
2. Integrated treatments- alcohol counselors and PTSD therapists work as a team (26, 27)
X. Primary Care Treatment of Trauma and Alcoholism (28-31)
1. Assess symptoms
2. Assess in detail the patientís response to symptoms
a. Over the counter medication use
b. Alcohol or other substance use
3. Psychosocial history
4. Behavioral health history
5. Trauma history (28, 29)
B. Screening and brief intervention for AUD (32, 33)
1. Quantity frequency interview
a. How many days a week do you drink?
b.How much on typical drinking day?
c. What is the most you had had to drink on one day?
2. Education about at-risk drinking
a. Men > 5 drink/d or 14 drinks /week
b. Women > 3 drinks/d or 7 drinks /week
3. Stage specific prevention messages
Alcohol risk level (abstinent, non-problem use, at-risk use, abuse, dependence)
e. Secure agreement
f. Set follow-up
A. Alcohol Use Disorders and PTSD commonly co-occur
1. Epidemiologic Data
2. Clinical data
B. Diagnosis of both disorders is essential for successful treatment
1. Co-occurring disorders present with more severity and need intensive treatment
2. Untreated symptoms of one disorder may interfere with compliance with treatment for other disorder
C. Combined therapies have better outcomes
1. Patients and providers may misinterpret isolated symptoms and implement ineffective or detrimental interventions
2. Combined and Integrated treatment approaches carefully consider the relationships of symptoms and interactions with treatment interventions.
D. All physicians have treatment opportunities
1. Patients may misinterpret physical symptoms of anxiety and seek care from primary care physicians or specialists
2. The skilled physician may accurately diagnosis the physical symptoms as related to alcohol or trauma or both
3. The physician may utilized brief counseling techniques for effective treatment.
(1) National Institute on Alcohol Abuse and Alcoholism. The Physicianís Guide to Helping Patients with Alcohol Problems (NIH publication No. 95-3769). Rockville, Maryland: NIAAA, 1995
(2) Schuckit, M.A. Drug and Alcohol Abuse: A clinical guide to diagnosis and treatment, Fifth Edition, New York, Kluwer Academic/Plenum Publishers, 2000.
(3) Schuckit, M.A., Daeppen, J-B., Tipp, J. E., Hesselbrock, M. and Bucholz, K.K. The clinical course of alcohol-related problems in alcohol dependent and nonalcohol dependent drinking women and men. J. Stud. Alcohol 1998; 59: 581-590.
(4) Schuckit, M.A., Tipp, J.E., Smith, T.L. and Bucholz, K.K. Periods of abstinence following the onset of alcohol dependence in 1,853 men and women. J. Stud. Alcohol 1997;58: 581-589.
(5) Ursano RJ. Post-traumatic stress disorder. N Engl J Med 2002;346:130-2
(6) McFarlane AC. Posttraumatic stress disorder: a model of the longitudinal course and the role of risk factors. J Clin Psychiatry. 2000;61 Suppl 5:15-20; discussion 21-3.
(7) Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995; 52:1048-60.
(8) Breslau N. The epidemiology of posttraumatic stress disorder: what is the extent of the problem? J Clin Psychiatry. 2001;62 Suppl 17:16-22.
(9) Breslau N, Davis GC, Peterson EL, Schultz L. Psychiatric sequelae of posttraumatic stress disorder in women. Arch Gen Psychiatry. 1997;54:81-7.
(10) Bromet E, Sonnega A, Kessler RC. Risk factors for DSM-III-R posttraumatic stress disorder: findings from the National Comorbidity Survey. Am J Epidemiol. 1998 Feb 15;147:353-61.
(11) Calhoun PS, Bosworth HB, Grambow SC, Dudley TK, Beckham JC. Medical service utilization by veterans seeking help for posttraumatic stress
disorder. Am J Psychiatry 2002;159:2081-6
(12) McFarlane AC. Epidemiological evidence about the relationship between PTSD and alcohol abuse: the nature of the association. Addictive Behaviors 1998;23:813-825.
(13) Giaconia RM, Reinherz HZ, Hauf AC, Paradis AD, Wasserman MS, Langhammer DM. Comorbidity of substance use and post-traumatic stress disorders in a community sample of adolescents. Am J Orthopsychiatry. 2000; 70:253-62.
(14) Deykin EY, Buka SL. Prevalence and risk factors for posttraumatic stress disorder among chemically dependent adolescents. Am J Psychiatry 1997; 154:752-7.
(15) Kofoed L, Friedman MJ, Peck R. Alcoholism and drug abuse in patients with PTSD. Psychiatr Q. 1993;64:151-71.
(16) Jacobsen LK, Southwick SM, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. Am J Psychiatry 2001; 158:1184-90.
(17) Fuller RK, Hiller-Sturmhofel S. Alcoholism treatment in the United States. An overview. Alcohol Res Health 1999;23:69-77
(18) O'Connor PG, Schottenfeld RS. Patients with alcohol problems. N Engl J
(19) Longabaugh R, Morgenstern J. Cognitive-behavioral coping-skills therapy for alcohol dependence. Current status and future directions. Alcohol Res Health 1999;23:78-85
(20) Johnson BA, Ait-Daoud N. Medications ro treat alcoholism. Alcohol Res Health 1999;23:99-105.
(21) Rothbaum BO, Schwartz AC. Exposure therapy for posttraumatic stress disorder. Am J Psychotherapy, 2002;5659-75
(22) Perkins BR, Rouanzoin CC. A critical evaluation of current views regarding eye movement desensitization and reprocessing (EMDR): clarifying points of confusion. J Clin Psychology,2002;58:77-97
(23) Albucher RC, Liberzon I. Psychopharmacological treatment in PTSD: a critical review. J Psychiatr Res 2002;36:355-67
(24) ) Najavits LM, Weiss RD, Shaw SR, Muenz LR. "Seeking safety": outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence. J Trauma Stress,1998;11:437-56.
(25) Ouimette PC, Brown PJ, Najavits LM. Course and treatment of patients with both substance use and posttraumatic stress disorders. Addict Behav. 1998;23:785-95.
(26) Weiss RD, Greenfield SF, Najavits LM. Integrating psychological and pharmacological treatment of dually diagnosed patients. NIDA Res Monogr. 1995;150:110-28.
(28) Maes M, Delmeire L, Mylle J, Altamura C. Risk and preventive factors of post-traumatic stress disorder (PTSD): alcohol consumption and intoxication prior to a traumatic event diminishes the relative risk to develop PTSD in response to that trauma. J Affect Disord. 2001;63:113-21.
(29) Pfefferbaum B, Doughty DE. Increased alcohol use in a treatment sample of Oklahoma City bombing victims. Psychiatry. 2001;64:296-303.
(30) Vlahov D, Galea S, Resnick H, Ahern J, Boscarino JA, Bucuvalas M, Gold J,Kilpatrick D. Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, residents after the September 11th terrorist attacks.
Am J Epidemiol. 2002;155:988-96.
(31) Zatzick DF, Jurkovich GJ, Gentilello L, Wisner D, Rivara FP. Posttraumatic stress, problem drinking, and functional outcomes after injury. Arch Surg. 2002;137:200-5.
(32) Fleming M, Manwell LB. Brief intervention in primary care settings: A primary treatment method for at-risk, problem, and dependent drinkers. Alcohol Res Health 1999;23:128-137.
(33) Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26:36-43