ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER

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ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER

• Joe E. Thornton, M.D.

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Significance

• Alcoholism and Posttraumatic Stress Disorder
  (PTSD) are common
• Symptoms overlap
• Co-occurrence increases severity
• Most physicians know little about either but will
  treat at-risk patients

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Dilemma

• People may increase alcohol use in response to
  trauma
• Alcoholism could temporarily mimic PTSD
• Alcoholism makes preexisting disorders (including
  PTSD) worse

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Lecture Overview

• Clinical information on alcoholism
• Clinical information on PTSD
• Strategies for diagnoses and treatment
• Strategies for primary care treatment
  interventions

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Alcohol Use
Spectrum
NON-PROBUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence
- - -
- -
-/ -


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Alcoholism Definition

• Alcoholism Alcohol Use Disorders
• DSM-IV Alcohol Use Disorders
• Alcohol dependence
• Alcohol abuse
• Alcoholism may be complicated by alcohol induced
  disorders

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Alcohol Dependence

• In the past 12 months 3 of
• Tolerance
• Withdrawal
• More use
• Loss of control
• Significant time
• Giving up important activities
• Continued use

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Alcohol Abuse

• Repetitive pattern of harmful behaviors 1 of
• Failure to fulfill major role obligations
• Physically hazardous use
• Legal problems related to use
• Interpersonal problems related to use

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Alcoholism Prevalence

• Abuse
• Men 13
• Women 6
• Dependence
• Men 20
• Women 8

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Clinical Course

• Early milestones similar to population
• First drink age 13
• First intoxication age 16
• First problem age 21
• 40 of all drinkers have some minor problem at
  some time

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Clinical Course

• Dependence age 28
• Variable course
• Frequent periods of abstinence
• Any given month 50 of alcoholics are abstinent
• Spontaneous remissions 20

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Medical Morbidity

• Dependence cuts 15 years off the lifespan
• Deaths from
• Heart disease
• Cancer
• Accidents
• Suicide

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Psychiatric Symptoms in Alcoholism

• Almost 100 have insomnia and bad dreams
• 40 experience
• Depression
• Anxiety
• Psychosis
• Other alcohol induced disorders
• Symptoms resolve with abstinence

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Trauma Spectrum
Acute Stress Disorder
Transient or no symptoms

PTSD
None


-/ -
-
- -
Trauma Consequences Impairment gt
30d Re-experience, arousal and avoidant symptoms
Co-occurring syndromes
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PTSD Definition

• DSM-IV Posttraumatic stress disorder
• History of traumatic event
• Person experienced, witnessed, or was confronted
  with a disturbing event
• Response was intense fear, helplessness, or horror

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PTSD Definition

• Re-experienced as 1 symptoms
• Arousal as evidenced by 2 symptoms
• Avoidance indicated by 3 symptoms

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PTSD Definition

• Duration gt1 month
• Symptoms significant

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PTSD Prevalence

• 70 persons in US exposed to 1 trauma
• 11 of trauma-exposed persons develop PTSD
• Prevalence of PTSD
• Men 5
• Women 10

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Risks for PTSD

• Trauma severity
• Prior trauma
• Prior psychiatric history
• Peritraumatic dissociation
• Autonomic hyperarousal
• Acute stress symptoms

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PTSD Clinical Course

• Onset follows Acute Stress Disorder
• Variable course
• Spontaneous remission uncommon
• Physical symptoms common
• No definitive link with physical health or
  mortality

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PTSD and Alcoholism

• Community patients with PTSD have 2x alcoholism
• Patients seeking treatment for alcoholism have
  3x PTSD
• Substance dependence adolescent inpatients have
  5x PTSD
• Inpatient alcohol rehabilitation adult women have
  5x PTSD

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Symptoms

• Insomnia
• Nightmares
• Irritability
• GI distress
• Tachycardia
• Dyspnea
• Tremor

• Fatigue
• Concentration impaired
• Poor recall
• Decreased interests
• Emotional blunting

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Diagnostic Strategies

• Age of onset alcoholism
• Periods of abstinence
• Age of trauma
• ? PTSD existed before alcoholism or after 3
  months of abstinence
• Findings dictate treatment

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Alcoholism Treatment

• Cognitive/behavioral
• Increase motivation
• Help restore functioning
• Relapse prevention
• Intense treatment 2-4 weeks
• Then less intense for 6 months
• Self-help groups
• Limited role for medications (naltrexone)

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PTSD Treatment

• Cognitive/behavioral (e.g. Exposure Therapy)
• Patient confronts event
• Patient educated about common reactions to trauma
• Patient is trained in behavioral symptom
  management
• Patient progressively masters the symptom
  response
• Medications
• SSRI antidepressants

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Alcoholism and PTSD Wait and Treat

• Achieve abstinence and monitor PTSD symptoms
• Control PTSD symptoms and monitor alcohol
  abstinence
• Sequential treatment
• Treat the most disabling syndrome first
• If second syndrome still present after time then
  treat

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Alcoholism and PTSD Comprehensive Treatment

• Coordinated treatments
• Alcohol counselors communicate with therapists
  treating PTSD
• Integrated treatments
• Alcohol counselors and PTSD therapists work as a
  team

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Treatment in Primary Care

• Assess symptoms
• Assess in detail patients response to symptoms
• Over the counter medicines
• Alcohol or other substance use
• Psychosocial history
• Behavioral health history

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Alcoholism Treatment in Primary Care

• Quantity /frequency interview
• How many days a week do you drink?
• How much on typical drinking day?
• What is the most you had had to drink on one day?
• Education about at-risk drinking
• Men gt 5 drink/day or 14 drinks/week
• Women gt 3 drinks/day or 7 drinks/week

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Brief Treatment

• Risk behavior education interventions
• Stage specific messages
• Abstinent
• Non-problem use
• At-risk use
• Abuse, dependence

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Counseling (FERNSS)

• Feedback
• Education
• Recommendation
• Negotiation
• Secure agreement
• Set follow-up

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Summary

• Alcoholism and PTSD commonly co-occur
• Diagnosis of both disorders is essential for
  successful treatment
• Comprehensive treatment incorporates the
  interactions of symptoms with treatment
• All physicians have treatment opportunities