Consistency of retrospective reports of DSM-IV criterion A traumatic stressors among substance use disorder patients

Post-traumatic stress disorder and drug use disorder: examination of aetiological models in a Swedish population-based cohort

Background: There are two primary phenotypic models of comorbidity between post-traumatic stress disorder (PTSD) and drug use disorder (DUD), i.e. self-medication (PTSD precedes and causes DUD) and susceptibility (DUD precedes and causes PTSD). We sought to clarify the longitudinal relationship between PTSD and DUD, while examining sex differences.Method: We used approximately 23 years of longitudinal data from Swedish population registries to conduct two complementary statistical models: Cox proportional hazard models (N ≈ 1.5 million) and a cross-lagged panel model (N ≈ 3.8 million).Results: Cox proportional hazards models, adjusting for cohort and socioeconomic status, found strong evidence for the self-medication hypothesis, as PTSD predicted increased risk for DUD among both women [hazard ratio (HR) = 5.34, 95% confidence interval (CI) 5.18, 5.51] and men (HR = 3.65, 95% CI 3.54, 3.77), and moreover, that the PTSD to DUD association was significantly higher among women (interaction term 0.68, 95% CI 0.65, 0.71). The results of the susceptibility model were significant, but not as strong as the self-medication model. DUD predicted risk for PTSD among both women (HR = 2.43, 95% CI 2.38, 2.50) and men (HR = 2.55, 95% CI 2.50, 2.60), and HR was significantly higher in men (interaction term 1.05, 95% CI 1.02, 1.08). Investigating the pathways simultaneously in the cross-lagged model yielded support for both pathways of risk. The cross-paths instantiating the susceptibility model (0.10-0.22 in females, 0.12-0.19 in males) were mostly larger than those capturing the self-medication model (0.01-0.16 in females, 0.04-0.22 in males).Conclusions: We demonstrate that the relationship between PTSD and DUD is bidirectional, with evidence that future research should prioritize examining specific pathways of risk that may differ between men and women.

Music therapy for people with substance use disorders

BACKGROUND

Substance use disorder (SUD) is the continued use of one or more psychoactive substances, including alcohol, despite negative effects on health, functioning, and social relations. Problematic drug use has increased by 10% globally since 2013, and harmful use of alcohol is associated with 5.3% of all deaths. Direct effects of music therapy (MT) on problematic substance use are not known, but it may be helpful in alleviating associated psychological symptoms and decreasing substance craving.

OBJECTIVES

To compare the effect of music therapy (MT) in addition to standard care versus standard care alone, or to standard care plus an active control intervention, on psychological symptoms, substance craving, motivation for treatment, and motivation to stay clean/sober.

SEARCH METHODS

We searched the following databases (from inception to 1 February 2021): the Cochrane Drugs and Alcohol Specialised Register; CENTRAL; MEDLINE (PubMed); eight other databases, and two trials registries. We handsearched reference lists of all retrieved studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials comparing MT plus standard care to standard care alone, or MT plus standard care to active intervention plus standard care for people with SUD.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We included 21 trials involving 1984 people. We found moderate-certainty evidence of a medium effect favouring MT plus standard care over standard care alone for substance craving (standardised mean difference (SMD) -0.66, 95% confidence interval (CI) -1.23 to -0.10; 3 studies, 254 participants), with significant subgroup differences indicating greater reduction in craving for MT intervention lasting one to three months; and small-to-medium effect favouring MT for motivation for treatment/change (SMD 0.41, 95% CI 0.21 to 0.61; 5 studies, 408 participants). We found no clear evidence of a beneficial effect on depression (SMD -0.33, 95% CI -0.72 to 0.07; 3 studies, 100 participants), or motivation to stay sober/clean (SMD 0.22, 95% CI -0.02 to 0.47; 3 studies, 269 participants), though effect sizes ranged from large favourable effect to no effect, and we are uncertain about the result. There was no evidence of beneficial effect on anxiety (mean difference (MD) -0.17, 95% CI -4.39 to 4.05; 1 study, 60 participants), though we are uncertain about the result. There was no meaningful effect for retention in treatment for participants receiving MT plus standard care as compared to standard care alone (risk ratio (RR) 0.99, 95% 0.93 to 1.05; 6 studies, 199 participants). There was a moderate effect on motivation for treatment/change when comparing MT plus standard care to another active intervention plus standard care (SMD 0.46, 95% CI -0.00 to 0.93; 5 studies, 411 participants), and certainty in the result was moderate. We found no clear evidence of an effect of MT on motivation to stay sober/clean when compared to active intervention, though effect sizes ranged from large favourable effect to no effect, and we are uncertain about the result (MD 0.34, 95% CI -0.11 to 0.78; 3 studies, 258 participants). There was no clear evidence of effect on substance craving (SMD -0.04, 95% CI -0.56 to 0.48; 3 studies, 232 participants), depression (MD -1.49, 95% CI -4.98 to 2.00; 1 study, 110 participants), or substance use (RR 1.05, 95% CI 0.85 to 1.29; 1 study, 140 participants) at one-month follow-up when comparing MT plus standard care to active intervention plus standard care. There were no data on adverse effects. Unclear risk of selection bias applied to most studies due to incomplete description of processes of randomisation and allocation concealment. All studies were at unclear risk of detection bias due to lack of blinding of outcome assessors for subjective outcomes (mostly self-report). We judged that bias arising from such lack of blinding would not differ between groups. Similarly, it is not possible to blind participants and providers to MT. We consider knowledge of receiving this type of therapy as part of the therapeutic effect itself, and thus all studies were at low risk of performance bias for subjective outcomes.  We downgraded all outcomes one level for imprecision due to optimal information size not being met, and two levels for outcomes with very low sample size.  AUTHORS' CONCLUSIONS: Results from this review suggest that MT as 'add on' treatment to standard care can lead to moderate reductions in substance craving and can increase motivation for treatment/change for people with SUDs receiving treatment in detoxification and short-term rehabilitation settings. Greater reduction in craving is associated with MT lasting longer than a single session. We have moderate-to-low confidence in our findings as the included studies were downgraded in certainty due to imprecision, and most included studies were conducted by the same researcher in the same detoxification unit, which considerably impacts the transferability of findings.

Comparing and Predicting Inconsistency on Positive and Negative Life Experiences Reports: Which Variables Matter?

Most studies about life experiences and their long-term impact have relied on retrospective assessments and cross-sectional designs. However, there are concerns about the inconsistency of reports, which have been addressed in a limited scope. This study aimed to compare differences on inconsistency between positive and negative experiences to describe potential patterns and to identify sociodemographic, experiences-related and design-related predictors of inconsistency. Adults from community (N = 171) reported their life experiences twice, through self-report or interview. An overall trend of overreporting was found for positive and negative experiences. Additionally, inconsistency on positive experiences was higher than on negative although both variables were correlated. Regarding predictors of inconsistency, the model explained greater variance for negative experiences than for the positive ones. Nevertheless, most variables did not predict inconsistency, with few exceptions: impact for positive experiences, total of experiences for negative experiences, and time interval was marginally significant for both. Available data comparing inconsistency on positive and negative experiences as well as associated predictors are incipient. Overall, it seems that we know more about variables not involved in inconsistency than those that matter. Due to its relevancy, this issue should be further examined.

Internalizing and externalizing subtypes in female patients with co-occurring post-traumatic stress disorder and substance use disorders

BACKGROUND

Research has described subtypes with more internalizing and more externalizing symptoms in samples of patients with post-traumatic stress disorder (PTSD) and samples of patients with substance use disorders (SUD).

OBJECTIVE

This study sought to examine the respective subtypes in female PTSD-SUD patients and potential relationships with substance use characteristics.

METHODS

We performed a latent class analysis (LCA) in 343 adult female participants of a multisite therapy trial on PTSD and SUD. We derived externalizing symptoms from the Assessment of DSM-IV Personality Disorders (ADP-IV) questionnaire. We assessed internalization using the Symptom Checklist-27 (SCL-27) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). We collected substance use-related information using the Addiction Severity Index-Lite (ASI-lite).

RESULTS

LCA suggested four latent classes including an externalizing (10.8%), a moderately internalizing class (31.0%), and a highly internalizing class (22.0%), as well as a class with a low severity of psychological symptoms (36.3%). Externalizing participants used more substances than any other class, while the duration of substance use did not differ between groups. Regular use started at a significantly younger age among the members of the highly internalizing subgroup compared to the moderately internalizing and low severity participants, but at an older age compared to the externalizing group members.

CONCLUSIONS

The finding of two internalizing subgroups along with an externalizing and a low severity class emphasizes the heterogeneity and complexity of populations with PTSD and SUD. This heterogeneity bears implications for research among this group of patients, but also for their treatment, especially considering our results on differences in substance use.

Music Therapy to Regulate Arousal and Attention in Patients With Substance Use Disorder and Posttraumatic Stress Disorder: A Feasibility Study

Patients diagnosed with both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) often experience hypervigilance, increased fear, and difficulties regulating emotions. This dual diagnosis increases treatment complexity. Recently, a short-term music therapy intervention for arousal and attention regulation (the SMAART intervention) was designed based on neurobiological findings. Twelve patients with SUD and PTSD (50% females) in outpatient treatment participated in six weekly one-hour sessions of the SMAART intervention. Six patients completed the study. PTSD symptom severity was evaluated with the Posttraumatic Stress Disorder Symptom Scale Interview for DSM-5 (PSSI-5) pre- and post-intervention, and sustained attention was evaluated with the Bourdon-Wiersma (BW) test. A significant difference in measurements for the PSSI-5 overall symptom severity was found pre- and post-intervention. Furthermore, participants showed significant improvement on subscales of hyperarousal, mood and cognition, and attention. The BW test completion time decreased significantly. Two participants dropped out before the end of the intervention due to craving. Concerning future research, it is recommended to define the role of the music more explicitly and to change the design to a randomized controlled trial. A risk for future larger studies is a high dropout rate (50%). Several limitations of the study are discussed.

Efficacy of Behavioral Couples Therapy Versus Individual Recovery Counseling for Addressing Posttraumatic Stress Disorder Among Women With Drug Use Disorders

Behavioral couples therapy (BCT) for substance use disorder shares similar intervention strategies with empirically supported couples therapies for posttraumatic stress disorder (PTSD). Like couples-based PTSD therapies, BCT includes interventions that may help to improve PTSD, such as increasing positive behavioral exchanges and improving communication. Studies have yet to examine whether BCT, which has demonstrated efficacy for improving substance-related outcomes, is efficacious for reducing PTSD. We conducted a secondary analysis of a randomized clinical trial comparing individually based treatment (IBT) to BCT plus IBT (BCT+IBT) for women with drug use disorders. Women in both conditions received 26 therapy sessions over 13 weeks. Women completed the PTSD Diagnostic Scale at baseline, posttreatment, and quarterly during the 1-year follow-up. Of the 61 women who were randomized to treatment, 51 (83.6%) reported a lifetime traumatic event. Of the 50 women who endorsed a "worst traumatic event," 25 (50.0%) had a baseline PTSD diagnosis. The treatments did not differ on baseline PTSD severity or diagnosis. Women who received BCT+IBT had significant reductions in PTSD severity from baseline to each of four posttreatment follow-ups, ds = 0.34-0.80; there were no changes in the IBT group. Generalized estimating equation results showed that women who received BCT+IBT had significantly lower PTSD severity during follow-up versus those who received IBT, d = 0.35. There were no differences in the proportion of participants diagnosed with PTSD following treatment. This was the first study to show that BCT+IBT is efficacious for reducing PTSD among women with drug use disorders.

PTSD Symptom Severity, Cannabis, and Gender: A Zero-Inflated Negative Binomial Regression Model

INTRODUCTION

In the general population, significant relations have been shown between experienced trauma and cannabis use. Approximately three out of four college students report experiencing at least one-lifetime traumatic event, putting them at greater risk for developing substance use disorder (SUD), and college students report using cannabis to cope with negative effect and stress. However, PTSD symptom severity predicting cannabis use in the college population has not been investigated.

METHODS

This cross-sectional survey study investigated the relation between PTSD symptom severity and cannabis use, and explored the moderating effect of gender on this relation, using a non-directional, exploratory analysis, in a sample of college students (N = 536; 68% female). Due to excessive zero values in the primary outcome, a zero-inflated negative binomial regression model was used.

RESULTS

Gender predicted number of cannabis using days [incidence rate ratio (IRR) = 2.17; 95%CI = 1.41, 3.35; p < .001]. The probability of being a cannabis user was moderated by gender [odds ratio (OR) = 0.96; 95%CI= 0.93, 0.99; p = .026], such that for males, as PTSD symptom severity increased, likelihood of being a cannabis user increased. This relation was not supported in females, however. Conclusion/Implication: Discussion includes the potential role of the endocannabinoid system, social norms, and motives in gender differences in PTSD-related cannabis use, and explores the self-medication hypothesis in this context.

Sexual Assault Characteristics and Perceptions of Event-Related Distress

Sexual assault (SA) is a potent psychological stressor, linked to harmful mental health outcomes in both the short- and long-term. Specific assault characteristics can add to the toxicity of SA events. Although research has assessed characteristics of the assault itself (e.g., force, penetration), few studies have examined the larger socioenvironmental context in which SA takes place. This was the purpose of the present study. Young adults ( N = 220; 80% female; 54% current students) reported on their most recent SA during college. Cross-sectional associations were tested via structural equation modeling to determine the contributions of socioenvironmental context and assault characteristics in predicting event-related distress. Socioenvironmental context from the most recent assault included assault setting, intoxication at the time of the assault, perpetrator relationship, and prior consensual sexual experiences with the perpetrator. We also examined assault characteristics, including physical force and penetration. Participants reported how upsetting the most recent assault was (a) at the time it occurred and (b) currently. Results revealed differential patterns for socioenvironmental context and assault characteristics based on the timing of distress (past or present). Notably, many of the socioenvironmental factors showed associations with distress above and beyond the powerful effects of physical force and penetration. These findings have important implications for our understanding of the unique factors that contribute to and maintain psychological distress in sexually victimized young adults.

Using the Pictorial Representation of Illness and Self Measure (PRISM) to Quantify and Compare Suffering From Trauma and Addiction

OBJECTIVE

In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems.

METHODS

The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM).

RESULTS

No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems.

CONCLUSIONS

This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs.

Predator-scent stress, ethanol consumption and the opioid system in an animal model of PTSD

Emerging literature points to stress exposure as a potential contributor to the development of alcohol abuse, but animal models have yielded inconsistent results. Converging experimental data indicate that the endogenous opioid system modulates alcohol consumption and stress regulation. The aim of the present study is to examine the interplay between stress exposure, behavioral stress responses, ethanol (EtOH) consumption and the endogenous opioid system in an animal model of posttraumatic stress disorder. Rats were exposed to stress and then tested in a two-bottle free choice (TBC) assay or in a conditioned place preference paradigm. In some experiments, the endogenous opioid system was pharmacologically manipulated prior to stress exposure. The behavioral outcomes of stress exposure were assessed in an elevated plus-maze, with the acoustic startle response, and by monitoring the freezing response to trauma reminder. Immunoreactivity of phosphorylated opioid receptors in hippocampal subregions was also measured. Stress significantly increased the consumption of EtOH in the TBC assay. The severity of the behavioral response to stress was associated with EtOH consumption, cue-triggered freezing response to a trauma reminder, and endogenous levels of phosphorylated opioid receptors in the hippocampus. Pharmacologically manipulating the endogenous opioid system prior to stress exposure attenuated trauma cue-triggered freezing responses and blocked predator scent stress-induced potentiation of EtOH consumption. These data demonstrate a stress-induced potentiation of EtOH self-administration and reveal a clear association between individual patterns of the behavioral response to stress and alcohol preference, while indicating a role for the endogenous opioid system in the neurobiological response to stress.

Examining the Role of Antisocial Personality Disorder in Intimate Partner Violence Among Substance Use Disorder Treatment Seekers With Clinically Significant Trauma Histories

This study examined the associations among posttraumatic stress disorder (PTSD) symptom severity, antisocial personality disorder (ASPD) diagnosis, and intimate partner violence (IPV) in a sample of 145 substance abuse treatment-seeking men and women with positive trauma histories; sex was examined as a moderator. ASPD diagnosis significantly predicted both verbal and physical aggression; sex moderated the association between ASPD diagnosis and physical violence. PTSD symptom severity significantly predicted engaging in verbal, but not physical, aggression. Overall, these results suggest that an ASPD diagnosis may be an important risk factor for engaging in IPV among women seeking treatment for a substance use disorder.

Implementation of integrated therapies for comorbid post-traumatic stress disorder and substance use disorders in community substance abuse treatment programs

ISSUES

The high prevalence of trauma and post-traumatic stress disorder (PTSD) in individuals with substance use disorders (SUDs) presents a number of treatment challenges for community treatment providers and programs in the USA. Although several evidence-based, integrated therapies for the treatment of comorbid PTSD/SUD have been developed, rates of utilisation of such practices remain low in community treatment programs.

APPROACH

The goal of this article was to review the extant literature on common barriers that prevent adoption and implementation of integrated treatments for PTSD/SUD among substance abuse community treatment programs.

KEY FINDINGS

Organisational, provider-level and patient-level factors that drive practice decisions were discussed, including organisational philosophy of care policies, funding and resources, as well as provider and patient knowledge and attitudes related to implementation of new integrated treatments for comorbid PTSD and SUD.

IMPLICATIONS AND CONCLUSIONS

Understanding and addressing these community treatment challenges may facilitate use of evidence-based integrated treatments for comorbid PTSD and SUD.

Assessing traumatic experiences in screening for PTSD in substance use disorder patients: what is the gain in addition to PTSD symptoms?

Traumatic experiences have been linked with substance use disorders (SUD) and may be an important factor in the perpetuation of SUD, even in the absence of posttraumatic stress disorder (PTSD) symptoms. The purpose of the current study was to examine the relationship between childhood trauma and substance use severity in 192 SUD inpatients. Childhood trauma was assessed using the Traumatic Experiences Checklist (TEC). With variables derived from this measure in addition to PTSD symptoms, two regression models were created with alcohol use or drug use severity as dependent variables. Alcohol severity was explained by PTSD symptoms as well as the age of trauma. Drug severity was explained solely by PTSD symptoms. The clinical value of assessing childhood trauma in determining the addiction severity appears to be limited in comparison with PTSD symptoms.

Screening of current post-traumatic stress disorder in patients with substance use disorder using the Depression, Anxiety and Stress Scale (DASS-21): a reliable and convenient measure

BACKGROUND

Several instruments have been developed and validated as screens for post-traumatic stress disorder (PTSD) in substance use disorder (SUD) patients. Unfortunately, many of these instruments have one or several disadvantages (e.g. low specificity, low sensitivity or high costs). No research has been conducted on instruments that screen simultaneously for other psychiatric disorders, which would be a potentially time-saving and cost-effective approach. In the current study we tested the psychometric properties of the Depression, Anxiety and Stress Scale (DASS) as a screen for PTSD.

METHODS

The DASS was assessed in an inpatient facility during intake with 58 patients and again 4 weeks after admission. Another 138 patients were assessed 4 weeks after admission only. The results were compared to the Clinician-Administered PTSD Scale (CAPS) that was also administered after 4 weeks of abstinence.

RESULTS

ROC curve analyses showed an area under the curve of 0.84 for the DASS at intake and 0.78 for the DASS after 4 weeks' abstinence.

CONCLUSION

The DASS is therefore a reliable and convenient measure to use as a screen for PTSD in SUD patients.

PTSD and comorbid AUD: a review of pharmacological and alternative treatment options

BACKGROUND

Although posttraumatic stress disorder (PTSD) and alcohol use disorders (AUD) frequently co-occur there are no specific treatments for individuals diagnosed with these comorbid conditions. The main objectives of this paper are to review the literature on pharmacological options for PTSD and comorbid AUD, and to summarize promising behavioral and alternative interventions for those with these dual diagnoses.

METHODS

We conducted a comprehensive search on PsycINFO and MEDLINE/PubMed databases using Medical Subject Headings terms in various combinations to identify articles that used pharmacotherapy for individuals with dual diagnoses of PTSD and AUD. Similar strategies were used to identify articles on behavioral and alternative treatments for AUD and PTSD. We identified and reviewed six studies that tested pharmacological treatments for patients with PTSD and comorbid AUD.

RESULTS

The literature on treatment with US Food and Drug Administration approved medications for patients with dual diagnosis of PTSD and AUD is very limited and inconclusive. Promising evidence indicates that topiramate and prazosin may be effective in reducing PTSD and AUD symptoms in individuals with comorbidity. Seeking safety has had mixed efficacy in clinical trials. The efficacy of other behavioral and alternative treatments (mindfulness-based, yoga, and acupuncture) is more difficult to evaluate since the evidence comes from small, single studies without comparison groups.

CONCLUSION

There is a clear need for more systematic and rigorous study of pharmacological, behavioral, and alternative treatments for patients with dual diagnoses of PTSD and AUD.

Behavioural, emotional, and cognitive responses in European disasters: results of survivor interviews

In the European multi-centre study BeSeCu (Behaviour, Security, Culture), interviews were conducted in seven countries to explore survivors' emotional, behavioural, and cognitive responses during disasters. Interviews, either in groups or one-to-one, were convened according to type of event: collapse of a building; earthquake; fire; flood; and terror attack. The content analysis of interviews resulted in a theoretical framework, describing the course of the events, behavioural responses, and the emotional and cognitive processing of survivors. While the environmental cues and the ability to recognise what was happening varied in different disasters, survivors' responses tended to be more universal across events, and most often were adaptive and non-selfish. Several peri-traumatic factors related to current levels of post-traumatic stress were identified, while memory quantity did not differ as a function of event type or post-traumatic stress. Time since the event had a minor effect on recall. Based on the findings, several suggestions for emergency training are made.

Validation of two screening instruments for PTSD in Dutch substance use disorder inpatients

Posttraumatic stress disorder (PTSD) is highly prevalent in substance use disorder (SUD) populations. Because resources for extensive and thorough diagnostic assessment are often limited, reliable screening instruments for PTSD are needed. The aim of the current study was to test two short PTSD measures for diagnostic efficiency in predicting PTSD compared to the Clinician-Administered PTSD Scale (CAPS). The sample consisted of 197 SUD patients receiving residential substance use treatment who completed questionnaires regarding substance use and trauma-related symptoms, all abstinent from substance for 4weeks. The PTSD section of the Mini International Neuropsychiatric Interview plus (MINIplus) and the Self-Report Inventory for PTSD (SRIP) are compared to the CAPS. Results showed low sensitivity (.58) and high specificity (.91) for the PTSD section of the MINIplus. The SRIP showed high sensitivity (.80) and moderately high specificity (.73) at a cut-off score of 48. The prevalence of PTSD as measured with the CAPS was 25.4% current and 46.2% lifetime. Results indicate that the MINIplus, a short clinical interview, has insufficient quality as a screener for PTSD. The SRIP, however, is a reliable instrument in detecting PTSD in a SUD inpatient population in The Netherlands. Screening for PTSD is time efficient and increases detection of PTSD in SUD treatment settings.

Does maltreatment beget maltreatment? A systematic review of the intergenerational literature

In this article, the authors critically review the literature testing the cycle of maltreatment hypothesis which posits continuity in maltreatment across adjacent generations. That is, the authors examine whether a history of maltreatment victimization is a significant risk factor for the later perpetration of maltreatment. The authors begin by establishing 11 methodological criteria that studies testing this hypothesis should meet. They include such basic standards as using representative samples, valid and reliable measures, prospective designs, and different reporters for each generation. The authors identify 47 studies that investigated this issue and then evaluate them with regard to the 11 methodological criteria. Overall, most of these studies report findings consistent with the cycle of maltreatment hypothesis. Unfortunately, at the same time, few of them satisfy the basic methodological criteria that the authors established; indeed, even the stronger studies in this area only meet about half of them. Moreover, the methodologically stronger studies present mixed support for the hypothesis. As a result, the positive association often reported in the literature appears to be based largely on the methodologically weaker designs. Based on this systematic methodological review, the authors conclude that this small and methodologically weak body of literature does not provide a definitive test of the cycle of maltreatment hypothesis. The authors conclude that it is imperative to develop more robust and methodologically adequate assessments of this hypothesis to more accurately inform the development of prevention and treatment programs.

Impulsive behaviors as an emotion regulation strategy: examining associations between PTSD, emotion dysregulation, and impulsive behaviors among substance dependent inpatients

Recent investigations have demonstrated that posttraumatic stress disorder (PTSD) is associated with a range of impulsive behaviors (e.g., risky sexual behavior and antisocial behavior). The purpose of the present study was to extend extant research by exploring whether emotion dysregulation explains the association between PTSD and impulsive behaviors. Participants were an ethnically diverse sample of 206 substance use disorder (SUD) patients in residential substance abuse treatment. Results demonstrated an association between PTSD and impulsive behaviors, with SUD patients with PTSD reporting significantly more impulsive behaviors than SUD patients without PTSD (in general and when controlling for relevant covariates). Further, emotion dysregulation was found to fully mediate the relationship between PTSD and impulsive behaviors. Results highlight the relevance of emotion dysregulation to impulsive behaviors and suggest that treatments targeting emotion dysregulation may be useful in reducing impulsive behaviors among SUD patients with PTSD.

Alcohol use disorder history moderates the relationship between avoidance coping and posttraumatic stress symptoms

Avoidance coping (AVC) is common in individuals with posttraumatic stress disorder (PTSD) and in individuals with alcohol use disorder (AUD). Given that PTSD and AUD commonly co-occur, AVC may represent a risk factor for the development of comorbid posttraumatic stress and alcohol use. In this study, the relationship between AVC and PTSD symptoms (PTSS) was examined in individuals with versus without AUDs. Motor vehicle accident (MVA) victims were assessed 6 weeks postaccident for AUD history (i.e. diagnoses of current or past alcohol abuse or dependence) and AVC. PTSS were assessed 6 weeks and 6 months post-MVA. All analyses were conducted on the full sample of MVA victims as well as on the subset of participants who were legally intoxicated (blood alcohol concentration ≥ 0.08) during the accident. It was hypothesized that the relationship between AVC and PTSS would be stronger in those individuals with an AUD history and especially strong in the subset of individuals who were legally intoxicated during the MVA. Results were largely supportive of this hypothesis, even after controlling for in-hospital PTSS, gender, and current major depression. Early assessment of AUD history and avoidance coping may aid in detecting those at elevated risk for PTSD, and intervening to reduce AVC soon after trauma may help buffer the development of PTSD + AUD comorbidity.

Baseline functioning among individuals with posttraumatic stress disorder and alcohol dependence

Comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD) may lead to a complicated and potentially severe treatment profile. Our study examined 167 individuals with both PTSD and AD compared with 105 individuals with PTSD without an alcohol use disorder (AUD) and 240 individuals with AD without PTSD on baseline psychosocial functioning. We hypothesized that individuals with PTSD/AD would be more socially and functionally impaired than individuals with only one disorder. Results indicated that participants with PTSD/AD were more likely to be unemployed, have less education, and report less income and were less likely to live with a partner than the participants with only a single disorder. However, they did not differ on symptom severity within these disorders (drinking frequency/quantity, PTSD, and anxiety symptoms) with the exception of depression and alcohol craving. This contradicts clinical lore that comorbid patients are more impaired at treatment initiation and adds support for concurrent treatment as not only feasible but also possibly ideal for these patients.

Consistency of retrospective reports of peritraumatic responses and their relation to PTSD diagnostic status

Few studies have examined whether trauma-exposed individuals are consistent in their retrospective reports of how they reacted at the time of trauma exposure, and whether this phenomenon has any implications at the diagnostic level. In a series of three longitudinal studies (N = 113) with different timeframes, the authors prospectively investigated the consistency of peritraumatic response scores as a function of posttraumatic stress disorder (PTSD) diagnostic status. Across the three studies, consistency of scores was better among individuals who either did not develop PTSD or who remitted from it than among those whose PTSD did not remit. These results are consistent with the literature suggesting that compromised memory processes are related to sustained PTSD.

Posttraumatic stress disorder with and without alcohol use disorders: diagnostic and clinical correlates in a psychiatric sample

This study compared outpatients (n=196) with PTSD versus PTSD+alcohol use disorders (AUD) on clinical measures. PTSD+AUD patients were more likely to meet criteria for Borderline and Antisocial Personality Disorders. Emotion dysregulation may help account for the relationship between PTSD and AUD.

Young Investigator Award symposium

This article highlights the research presented at the inaugural meeting of Alcoholism and Stress: A Framework for future Treatment Strategies. This meeting was held on May 6-8, 2008 in Volterra, Italy. It is an international meeting dedicated to developing preventive strategies and pharmacotherapeutic remedies for stress- and alcohol-related disorders. For the first time, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) conferred a Young Investigator Award to promote the work of young researchers and highlight their outstanding achievements in the fields of addiction medicine and stress disorders. The awardees were Dr. Katie Witkiewitz (University of Washington), Dr. Andrew Holmes (NIAAA), Dr. Lara A. Ray (Brown University), Dr. James Murphy (University of Memphis), and Dr. Heather Richardson (The Scripps Research Institute). The symposium was chaired by Drs. Fulton Crews and Antonio Noronha.

Longitudinal changes in recalled perceived life threat after a natural disaster

BACKGROUND

Post-traumatic stress disorder (PTSD) diagnosis often depends on a retrospective, self-report of exposure to a life-threatening event.

AIMS

To examine the stability of recalled perceived life threat in a community sample exposed to a distinct stressful event.

METHOD

Five hundred and thirty-two Norwegian citizens who experienced the 2004 South-East Asia tsunami completed a self-report questionnaire 6 and 24 months post-disaster. The questionnaire measured perceived life-threat intensity, exposure, immediate stress response, psychopathology, personality dimensions, self-efficacy and social support.

RESULTS

Recalled threat intensity increased from 6 to 24 months (P<0.001). Recall amplification was associated with lack of PTSD symptom improvement (P<0.05), but not with degree of exposure, immediate stress response, mood or stress symptoms, personality, self-efficacy or social support.

CONCLUSIONS

Recall amplification of perceived life threat from a single stressful event occurs in the general population, it may hinder PTSD symptom improvement and it questions the diagnostic validity of PTSD.

Relationships between memory inconsistency for traumatic events following 9/11 and PTSD in disaster restoration workers

The present study examined the relationships between memories for a single incident traumatic event - the 9/11 attack on the World Trade Center (WTC)--and posttraumatic stress disorder (PTSD). 2641 disaster restoration workers deployed at the WTC site in the aftermath of the attack were evaluated longitudinally, one year apart, for PTSD, using clinical interviews. Their recollection of the traumatic events was also assessed at these times. The results showed that recall of traumatic events amplified over time and that increased endorsement of traumas at Time 2 was associated with more severe PTSD symptoms. It was also shown that, of all the exposure variables targeted, memory of the perception of life threat and of seeing human remains were differentially associated with PTSD symptoms. Implications of the results are also discussed.

Trauma Victim: Yes or No?

The aim of this study is to explore the reasons why it may be difficult to answer questions regarding violence, sexual abuse, and other potentially traumatic events (PTEs). Qualitative and quantitative methods are used with a nonrepresentative community sample of 628 women who respond to a Web survey. Altogether, 65% do not find it difficult to answer any PTE questions. Difficulties in answering occur more frequently with violence and sexual abuse items and are associated with exposure. Reasons for difficulties in answering include “event fit” (severity, frequency, force), “me as a victim” (responsibility, reactions, protection, memory), and “you as abuser” (intention, protection).

The stressor Criterion-A1 and PTSD: a matter of opinion?

Considerable controversy exists with regard to the interpretation and definition of the stressor "A1" criterion for Post Traumatic Stress Disorder (PTSD). At present, classifying an event as either traumatic (satisfying DSM-IV Criterion-A1 for PTSD), or non-traumatic (life event) is determined by the rater's subjective interpretation of the diagnostic criteria. This has implications in research and clinical practice. Utilizing a sample of 860 Australian adults, this study is the first to provide a detailed examination of the impact of event categorization on the prevalence of trauma and PTSD. Overall, events classified as non-traumatic were associated with higher rates of PTSD. Unanimous agreement between raters occurred for 683 (79.4%) events. As predicted, the categorization method employed (single rater, multiple rater-majority, multiple rater-unanimous) substantially altered the prevalence of Criterion-A1 events and PTSD, raising doubts about the functionality of PTSD diagnostic criteria. Factors impacting on the categorization process and suggestions for minimizing discrepancies in future research are discussed.

Does prior psychological health influence recall of military experiences? a prospective study

In a prospective study, we evaluated pre- and postdeployment psychological health on recall of risk factors to assess recall bias. Measures of the General Health Questionnaire (GHQ), PTSD Checklist (PCL), and symptom clusters from the PCL were obtained from 681 UK military personnel along with information on traumatic and protective risk factors. Postdeployment psychological health was more important in explaining recall of traumatic experiences than predeployment psychological health. Predeployment intrusive cluster scores were highly associated with traumatic exposures. Postdeployment, but not predeployment GHQ showed small effects for most risk factors. With the exception of intrusive thoughts, there is insufficient evidence to suggest predeployment psychological status would be useful in correcting for recall bias in subsequent cross-sectional studies.

Trauma and PTSD in patients with alcohol, drug, or dual dependence: a multi-center study

BACKGROUND

We investigated (1) the prevalence of posttraumatic stress disorder (PTSD) in treatment-seeking subjects with substance use dependence (SUD), (2) the association between comorbid PTSD and the severity and course of addiction and psychopathology, and (3) this association in patients with subsyndromal PTSD, and in trauma exposure without PTSD.

METHODS

In this cross-sectional study, 459 subjects in 14 German addiction treatment centers participated with alcohol-dependence (A) in 39.7%, drug-dependence (D) in 33.6%, or both (AD) 26.8%. The diagnostic measures included the International Diagnostic Checklists (IDCL), Posttraumatic Diagnostic Scale (PDS), Addiction Severity Index (ASI), and the Brief Psychiatric Rating Scale (BPRS). Associations between independent characteristics and outcomes were analysed by univariate and multivariate statistics.

RESULTS

25.3% of the subjects had PTSD confirmed by both IDCL and PDS with higher rates in the AD (34.1%) and D (29.9%) groups compared with group A (15.4%, p < 0.001). In 22.8%, PTSD was subsyndromal (either IDCL or PDS positive) without significant differences between SUD groups, and 18.3% met PTSD trauma criteria A without PTSD (exposure). After controlling for SUD and gender, trauma subgroups significantly differed regarding the onset of alcohol-related symptoms (p < 0.02), numbers of previous admissions (p < 0.03), severity of SUD (p < 0.001), current craving (p < 0.02), and psychopathology (p < 0.001). We observed the worst outcome in PTSD, while trauma exposure had no effects.

CONCLUSIONS

The prevalence of PTSD is higher in drug than in alcohol dependence. The more strictly PTSD is diagnosed (by interviewer and questionnaire) the more clearly are associations with characteristics of SUD. PTSD seems to be an independent risk factor for an unfavorable outcome of SUD.

Violence Breeds Violence: Childhood Exposure and Adolescent Conduct Problems

The relationships between childhood exposure to violence and adolescent conduct problems were investigated in a sample of 88 primiparous adolescent mothers and their children. Regression analyses revealed that witnessing violence and victimization prior to age 10 predicted delinquency and violent behaviors, even after controlling for prenatal maternal and early childhood externalizing problems. Social competency and depression during middle childhood moderated the relationship between victimization and violent behaviors for girls, but not boys: Lower levels of social competency and depression served as risk factors for delinquency among teenage girls who experienced victimization during childhood. These findings have important implications for youth violence prevention programs.

Reliability of self-reported trauma exposure among people with heroin dependence: a longitudinal investigation

Estimates of trauma exposure rely almost exclusively on retrospective self-reports; however, the reliability of these reports has received little attention. The present study examined the reliability of self-reported lifetime trauma exposure among 309 dependent heroin users over 2 years, and the factors associated with inconsistent recall. The correlation between the number of events reported at baseline and follow-up was .72; however, 87% of the sample reported at least one event inconsistently. Variability in reporting was associated with trauma type, a lifetime posttraumatic stress disorder, and antisocial personality disorder. These findings suggest that dependent heroin users are moderately reliable in their reports of trauma exposure, and their reports of trauma exposure are as reliable as those of nonsubstance use disordered samples.

Memory of childhood trauma before and after long-term psychological treatment of borderline personality disorder

The present study investigated the consistency of self-reports of childhood traumatic events in a sample of 50 patients with a borderline personality disorder (BPD) before and after 27 months of intensive treatment with schema focused therapy or transference focused psychotherapy. The mean number of reported sexual, physical and emotional traumatic events did not change following treatment. Test-retest correlations of the trauma-interview also indicated high stability of the total number of sexual, physical and emotional events reported. The majority of the patients, however, did no longer report at least one of the 33 listed events after psychotherapy, and the majority reported at least one event that they had not mentioned before the start of treatment. These findings were not related to type of treatment or changes in suppression, intrusions, avoidance of intrusions, dissociative symptoms, depressive symptoms, and borderline symptoms.

Prevalence and factors associated with alcohol and drug-related disorders in prison: a French national study

BACKGROUND

Most studies measuring substance-use disorders in prisons focus on incoming or on remand prisoners and are generally restricted to drugs. However, there is evidence that substance use initiation or continuation occurs in prison, and that alcohol use is common. The aim of this study is 1) to assess prevalence of both drug and alcohol abuse and dependence (DAD/AAD) in a national randomised cohort of French prisoners, short or long-term sentence 2) to assess the risk factors associated with DAD/AAD in prison. a stratified random strategy was used to select 1) 23 prisons among the different types of prison 2) 998 prisoners. Diagnoses were assessed according to a standardized procedure, each prisoner being assessed by two psychiatrists, one junior, using a structured interview (MINI 5 plus), and one senior, completing the procedure with an open clinical interview. At the end of the interview the clinicians met and agreed on a list of diagnoses. Cloninger's Temperament and Character Inventory (TCI) was also used.

RESULTS

More than a third of prisoners presented either AAD or DAD in the last 12 months. Cannabis was the most frequent drug and just under a fifth of prisoners had AAD. AAD and DAD were clearly different for the following: socio-demographic variables, childhood history, imprisonment characteristics, psychiatric comorbidity and Cloninger's TCI. Profiles of AAD in prison are similar to type II alcoholism.

CONCLUSION

Regular screening of AAD/DAD in prison, and specific treatment programmes taking into account differences between prisoners with an AAD and prisoners with a DAD should be a public health priority in prison.

Health and well being of substance use disorder patients with and without posttraumatic stress disorder

While studies link posttraumatic stress disorder (PTSD) to substance use disorders (SUDs), little is known about the health and functional status of patients with such comorbidity. This study examined the health and well being of SUD patients with and without PTSD. Participants were assessed using structured clinical interviews and self-administered questionnaires assessing chronic physical symptoms, and functional status and well being. PTSD was significantly associated with more cardiovascular, neurological, and total chronic physical symptoms. In addition, PTSD was significantly related to poorer functional status and well being, particularly in the mental health realm of functioning. The association between PTSD and mental health component of functional health and well-being remained significant after controlling for chronic physical symptoms and other comorbid psychopathology.