Characterization of comorbid PTSD in treatment-seeking alcohol dependent inpatients: Severity and personality trait differences

The association between PTSD symptom clusters and religion/spirituality with alcohol use among first responders

Alcohol misuse and posttraumatic stress disorder (PTSD) co-occur at high rates among first responders (e.g., law enforcement, firefighters, paramedics), underscoring the need to better understand these relations to inform intervention efforts. Identifying malleable processes relevant to the association between PTSD and alcohol among first responders could inform tailored interventions. An example of such a malleable process is spirituality. As such, the current study examined the unique relationships between PTSD symptom clusters and alcohol misuse, while also accounting for the role of select demographics and religion/spirituality, in a sample of first responders. A national online sample of first responders (N = 320) completed measures of PTSD symptomology, alcohol misuse, religion/spirituality and demographics. Hierarchical linear regression analyses revealed that PTSD Intrusion (Cluster B) symptom severity was associated with greater alcohol misuse and PTSD Avoidance (Cluster C) was associated with lower alcohol misuse. Additionally, positive and negative spiritual coping were also associated with alcohol misuse. In the context of similar research among military samples, findings suggest potentially unique associations between PTSD symptom clusters and alcohol misuse among first responders. Additionally, findings highlight the potentially protective role of religion/spirituality in this population. Future research should explore nuanced relationships between PTSD symptom clusters and alcohol misuse as well as the salience of spirituality/religion in this unique population.

Drugs age-of-onset as a signal of later post-traumatic stress disorder: Bayesian analysis of a census protocol

Individuals with PTSD have an increased risk of drug use disorders. Conversely, we aim to evaluate how early onset of alcohol, tobacco and psychoactive drugs use are associated with PTSD later in life. 2,193 brazilian young adults completed modularized assessments: The Trauma History Questionnaire, Post-Traumatic Stress Disorder Checklist-Civilian Version (PCL-C, transformed to PCL-5 through a crosswalk procedure), the Barratt Impulsivity Scale; and a survey on drug use with self-report questions about first use, current use, frequency, quantity, and interpersonal consequences. Bayesian inference and multivariate regression models were used to examine the effects on the risk of PTSD, considering different assumptions of information flow. Raw and unbiased (multivariate) estimates consistently revealed that earlier age of onset of alcohol and tobacco use increased risk for PTSD (Odds-ratios between 2.39 and 3.19 (Alcohol) and 1.82 to 2.05 (Tobacco). Among those who had PTSD (310), 10.3% (32) were very precocious at the onset age (12 to 18 years) of alcohol consumption (No-PTSD: 89 out 1883, 4.7%). Data supports a model in which age of onset effects are partially mediated by the number of trauma exposures. Early intoxication might suggest vulnerability for qualifying trauma events, or it may increase chances of exposure. Also, PTSD may be more likely to occur among trauma-exposed individuals with early intoxicating experiences due to alcohol or drug self-administration. The last possibility resonates with the idea that early intoxication might disrupt adolescent brain development, with a subsequent reduction in resilience when qualifying trauma events occur.

Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis

Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD.

Personality Traits and Traumatic Outcome Symptoms in Registered Nurses in the Aftermath of a Patient Safety Incident

OBJECTIVES

The purpose of this study was to investigate the relationship between personality traits (perfectionism and neuroticism) and the traumatic outcomes of reexperiencing, avoidance, and alcohol abuse severity of registered nurses (RNs) who have been involved with a patient safety incident (PSI). We hypothesized that higher scores for perfectionism and neuroticism would predict higher reexperiencing and avoidance symptoms in RNs in the aftermath of a PSI. Also, RNs with higher perfectionism and neuroticism sum scores would be more likely to abuse alcohol.

METHODS

A descriptive, correlational study design was used to characterize the relationships of personality traits and potential traumatic outcomes of RNs in the aftermath of a PSI. The Almost Perfect Scale-Revised, Neuroticism Scale, Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, and Alcohol Use Disorders Identification Test-Consumption measures were administered to RNs licensed in Oregon and New York.

RESULTS

Perfectionist-discrepancy personality traits (P < 0.01) were the strongest predictors for reexperiencing symptoms and neuroticism (P < 0.05) was the strongest predictor for avoidance symptoms, when controlling for sociodemographics and experience. We found a negative linear relationship between perfectionism-order and alcohol abuse severity (β = -0.15, P < 0.01; confidence interval, -0.24 to 0.05).

CONCLUSIONS

This study demonstrated a statistically significant relationship between perfectionism-discrepancy and reexperiencing as well as between neuroticism and reexperiencing and avoidance, each explaining 4% of variance of their model. The results add to the nurse second victim literature by validating 2 posttraumatic stress disorder symptoms in RNs in the aftermath of a PSI. Registered nurses with perfectionism-order were less likely to abuse alcohol.

Understanding low treatment seeking rates for alcohol use disorder: A narrative review of the literature and opportunities for improvement

Despite a well-documented global burden of disease attributable to alcohol use disorder (AUD), treatment seeking rates remain low. In this qualitative literature review, we address treatment seeking for AUD from a host of perspectives and summarize the literature on key factors. First, we summarize the rates of alcohol treatment seeking across various epidemiological surveys, spanning decades. Second, we discuss the definition of treatment seeking and 'what' is typically considered formal treatment. Third, we consider timing and discuss 'when' individuals are most likely to seek treatment. Fourth, we review the literature on 'who' is most likely to seek treatment, including demographic and clinical correlates. Fifth, we address the critical question of 'why' so few people receive clinical services for AUD, relative to the number of individuals affected by the disorder, and review barriers to treatment seeking at the treatment- and person-levels of analysis. Finally, we identify opportunities to improve treatment seeking rates by focusing on tangible points of intervention. Specifically, we recommend a host of adaptations to models of care including efforts to make treatment more appealing across stages of AUD severity, accept a range of health-enhancing drinking goals as opposed to an abstinence-only model, educate providers and consumers about evidence-based behavioral and pharmacological treatments, and incentivize the delivery of evidence-based services.

Traumatic Events in Dual Disorders: Prevalence and Clinical Characteristics

Psychological trauma has been identified in substance use disorders (SUD) as a major etiological risk factor. However, detailed and systematic data about the prevalence and types of psychological trauma in dual disorders have been scarce to date. In this study, 150 inpatients were recruited and cross-sectionally screened on their substance use severity, psychological trauma symptoms, comorbidities, and clinical severity. One hundred patients fulfilled criteria for a dual disorder, while 50 patients were diagnosed with only SUD. Ninety-four percent of the whole sample suffered from at least one lifetime traumatic event. The prevalence rates of Posttraumatic Stress Disorder diagnosis for dual disorder and only SUD was around 20% in both groups; however, patients with dual disorder presented more adverse events, more childhood trauma, more dissociative symptoms, and a more severe clinical profile than patients with only SUD. Childhood maltreatment can also serve as a predictor for developing a dual disorder diagnosis and as a risk factor for developing a more complex and severe clinical profile. These data challenge our current clinical practice in the treatment of patients suffering from dual disorder or only SUD diagnosis and favor the incorporation of an additional trauma-focused therapy in this population. This may improve the prognosis and the course of the illness in these patients.

Clinical presentations, social functioning, and treatment receipt among individuals with comorbid life-time PTSD and alcohol use disorders versus drug use disorders: findings from NESARC-III

AIMS

To compare individuals with comorbid life-time post-traumatic stress disorder (PTSD) and alcohol use disorders [AUD; i.e. no drug use disorders (DUD)] with those with comorbid PTSD and DUD on past-year prevalence of these disorders, social functioning, life-time psychiatric comorbidities, and treatment receipt. The comorbid groups were also compared with their single diagnosis counterparts.

DESIGN AND SETTING

Cross-sectional cohort study using data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC-III).

PARTICIPANTS

The total sample size was 36 309. Six groups were established: PTSD/AUD, PTSD/DUD, AUD, DUD, PTSD, and neither PTSD nor AUD/DUD. Life-time prevalence of AUD among those with PTSD/DUD was 80.2% and among those with DUD was 73.8%.

MEASUREMENTS

The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 version assessed life-time and past-year psychiatric disorders and treatment receipt. Demographics and social stability indicators were queried. Group characteristics were summarized using weighted means. Prevalences and estimates for adjusted differences in means and adjusted odds ratios (aORs) were derived from multiple linear regression and logistic regression models, respectively. Analyses were conducted in R and accounted for the NESARC-III's complex survey design, clustering, and non-response.

FINDINGS

Compared with those with life-time PTSD/AUD, those with life-time PTSD/DUD were significantly less likely to have neither disorder in the past year (PTSD/AUD = 16.1%; PTSD/DUD = 8.5%; aOR = 0.54), and were more likely to report worse social and psychiatric functioning, and to have received both addiction and mental health treatment (PTSD/AUD = 18.4%; PTSD/DUD = 43.2%; aOR = 3.88). Compared with their single disorder counterparts, those with PTSD/DUD reported greater impairment than both groups, whereas the comorbid PTSD/AUD group differed more from the AUD than the PTSD group.

CONCLUSIONS

People with comorbid PTSD and drug use disorder have greater social and psychiatric impairment and may require different types and intensity of intervention than people with comorbid post-traumatic stress disorder and alcohol use disorder.

The dissociative subtype of PTSD in women with substance use disorders: Exploring symptom and exposure profiles

The dissociative subtype of posttraumatic stress disorder (PTSD) was officially introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In accordance with this new classification, prior studies using Latent Class Analysis (LCA) empirically identified a subgroup of patients that were characterized by a high severity of dissociative symptoms. Despite the high prevalence of PTSD in patients with substance use disorders (SUD), however, no LCA studies on the dissociative subtype of PTSD exist in this population so far. Therefore, the current study aimed to identify subgroups of patients with different symptom and exposure profiles in patients with SUD and PTSD. It was assumed that one symptom and exposure profile could be identified that would be characterized by higher dissociative symptoms, higher additional psychopathology and a higher burden of childhood trauma, as compared to other subgroups. In N = 258 female patients with SUD and PTSD, clinical characteristics of dissociative symptoms, PTSD severity, borderline personality disorder (BPD), depression, childhood trauma and substance abuse were assessed. To identify symptom and exposure profiles, Latent Class Analysis was applied. A three-class solution indicated the best model fit to our data. One class was characterized by a high probability of dissociative symptoms (D-PTSD class), whereas the other two classes were characterized by lower probabilities of dissociative symptoms. The D-PTSD class encompassed 18.7% of the patients. In accordance with our hypothesis, the D-PTSD class showed higher probabilities of PTSD severity, borderline personality disorder symptoms, depressive symptoms, childhood emotional and sexual abuse, childhood emotional neglect, and drug abuse. Our results indicate that the dissociative subtype of PTSD could also be identified in a sample of female patients with SUD. Patients with SUD and PTSD characterized by the dissociative subtype showed more severe psychopathological symptoms than the remaining patients, indicating enhanced clinical needs for this vulnerable group.

A multisite randomized controlled trial of Seeking Safety vs. Relapse Prevention Training for women with co-occurring posttraumatic stress disorder and substance use disorders

Background: Co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with a more severe course and worse outcome than either disorder alone. In Europe, few treatments have been evaluated for PTSD and SUD. Seeking Safety, a manualized, integrated, cognitive-behavioural treatment, has been shown to be effective in studies in the USA. Objective: To test the efficacy of Seeking Safety plus treatment as usual (TAU) in female outpatients with PTSD and SUD compared to Relapse Prevention Training (RPT) plus TAU and TAU alone. Method: In five German study centres a total of N = 343 women were randomized into one of the three study conditions. PTSD severity (primary outcome), substance use, depression and emotion dysregulation (secondary outcomes) were assessed at baseline, post-treatment, as well as at three months and six months post-treatment. Results: Treatment participants attended M = 6.6 sessions (Seeking Safety) and M = 6.1 sessions (RPT). In an intent-to-treat analysis, Seeking Safety plus TAU, RPT plus TAU and TAU alone showed comparable decreases in PTSD severity over the course of the study. Seeking Safety plus TAU showed superior efficacy to TAU alone on depression and emotion regulation and RPT plus TAU was more effective than TAU alone on number of substance-free days and alcohol severity. Minimum-dose analyses suggest additional effects of both programmes among participants who attended at least eight group sessions. Conclusions: With respect to PTSD symptoms, a brief dose of Seeking Safety and RPT in addition to TAU was not superior to TAU alone in women with PTSD and SUD. However, Seeking Safety and RPT showed greater reductions than TAU alone in other domains of psychopathology and substance use outcomes respectively. Future studies should investigate further variables, such as what aspects of each treatment appeal to particular patients and how best to disseminate them.

Acceptance and Commitment Therapy for Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorders in Veterans: Pilot Treatment Outcomes

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur and are associated with worse outcomes together than either disorder alone. A lack of consensus regarding recommendations for treating PTSD-AUD exists, and treatment dropout is a persistent problem. Acceptance and Commitment Therapy (ACT), a transdiagnostic, mindfulness- and acceptance-based form of behavior therapy, has potential as a treatment option for PTSD-AUD. In this uncontrolled pilot study, we examined ACT for PTSD-AUD in 43 veterans; 29 (67%) completed the outpatient individual therapy protocol (i.e., ≥ 10 of 12 sessions). Clinician-assessed and self-reported PTSD symptoms were reduced at posttreatment, ds = 0.79 and 0.96, respectively. Self-reported symptoms of PTSD remained lower at 3-month follow-up, d = 0.88. There were reductions on all alcohol-related outcomes (clinician-assessed and self-reported symptoms, total drinks, and heavy drinking days) at posttreatment and 3-month follow-up, d_mean = 0.91 (d range: 0.65-1.30). Quality of life increased at posttreatment and follow-up, ds = 0.55-0.56. Functional disability improved marginally at posttreatment, d = 0.35; this effect became significant by follow-up, d = 0.52. Fewer depressive symptoms were reported at posttreatment, d = 0.50, and follow-up, d = 0.44. Individuals experiencing suicidal ideation reported significant reductions by follow-up. Consistent with the ACT theoretical model, these improvements were associated with more between-session mindfulness practice and reductions in experiential avoidance and psychological inflexibility. Recommendations for adapting ACT to address PTSD-AUD include assigning frequent between-session mindfulness practice and initiating values clarification work and values-based behavior assignments early in treatment.

Predator-based psychosocial stress model of PTSD differentially influences voluntary ethanol consumption depending on methodology

Post-traumatic stress disorder (PTSD) is a debilitating psychological disorder typified by diagnostic symptom clusters including hyperarousal, avoidance, negative cognitions and mood, and intrusive re-experiencing of the traumatic event. Patients with PTSD have been reported to self-medicate with alcohol to ameliorate hyperarousal symptoms associated with the disorder. Research utilizing rodent models of PTSD to emulate this behavioral phenomenon has thus far yielded inconsistent results. In the present study, we examined the effects of a predator-based psychosocial stress model of PTSD on voluntary ethanol consumption. In the first of two experiments, following exposure to a 31-day stress or control paradigm, rats were singly housed during the dark cycle with free access to 1% sucrose solution or 10% ethanol, which was also sweetened with 1% sucrose. Over the course of a 20-day period of ethanol access, stressed rats consumed significantly less ethanol than non-stressed rats. These counterintuitive results prompted the completion of a second experiment which was identical to the first, except rats were also exposed to the two-bottle paradigm for 20 days before the stress or control paradigm. In the second experiment, after the stress manipulation, stressed rats exhibited significantly greater ethanol preference than non-stressed rats. These findings suggest that prior exposure to ethanol influences the subsequent effect of stress on ethanol intake. They also validate the use of the present model of PTSD to examine potential mechanisms underlying stress-related changes in ethanol-seeking behavior.

Comorbid post-traumatic stress disorder in alcohol use disorder: relationships to demography, drinking and neuroimmune profile

BACKGROUND

This study examined how alcohol use disorder (AUD) patients with post-traumatic stress disorder (PTSD) differed from those without PTSD in terms of demography, drinking patterns and C-reactive protein, inflammatory cytokines, tryptophan metabolism parameters, and brain-derived neurotrophic factor (BDNF).

METHODS

A consecutive sample (N = 187) of treatment-receiving AUD individuals were recruited from Nepalese facilities. They underwent fully structured psychiatric interviews. Serum levels of inflammatory cytokines [interleukin (IL)-6, IL-1 Receptor antagonist (IL-1Ra), IL-10, tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ)] were determined by a multiplex assay, kynurenine and tryptophan levels by high-performance liquid chromatography, and BDNF by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The prevalence of exposure to severe trauma and PTSD was 74% and 17%, respectively. PTSD comorbidity was not associated with age, gender, or socioeconomic status, but with co-occurring major depression, history of attempted suicide, earlier peak of drinking problems, higher drinking quantity and withdrawal symptoms, experiencing alcoholic blackouts, and drinking problems among parents. None of the assessed neuroimmune parameters was related to comorbid PTSD.

CONCLUSIONS

The findings support routine trauma screening in AUD treatment samples and screening for risky drinking in trauma populations to help guide interventions. The expected aberrations in neuroimmune functioning may not be found when examined in a sample with multiple psychiatric morbidities.