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

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.

Functional and Psychiatric Correlates of Comorbid Post-Traumatic Stress Disorder and Alcohol Use Disorder

Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are common comorbid conditions that affect large segments of the population. Individuals with comorbid PTSD/AUD face greater clinical and functional stressors than those with diagnoses of either PTSD or AUD alone. The purpose of this article is to review the phenomenology and functional associations of PTSD/AUD and address the common social, occupational, and psychological concerns associated with both disorders. Given the increased problems associated with comorbid PTSD/AUD, clinical and research efforts should focus on targeting functional and psychosocial problems in conjunction with psychiatric symptoms.

[Substance use disorders as a cause and consequence of childhood abuse. Basic research, therapy and prevention in the BMBF-funded CANSAS-Network]

Substance use disorders (SUDs) belong to the most frequent behavioural consequences of childhood abuse and neglect (CAN). In community samples, about 20% of adults with experiences of abuse or neglect in childhood have a lifetime diagnosis of an SUD. About 30% of individuals seeking treatment for a post-traumatic disorder have an SUD and 24–67% of all patients in treatment for an SUD have a history of CAN. About 16% of all children and adolescents under the age of 20 in Germany grow up in families where an alcohol- and/or drug-dependence is present. The children of parents with SUDs have, in addition to other risks to their development in cognitive and psychosocial domains, an increased risk of experiencing violence and neglect. Regarding both perspectives, SUD as a cause and as a consequence of CAN, a better understanding of relevant mediators and risk factors is necessary to improve prevention and develop adequate treatments. The aims of the BMBF-funded research network CANSAS are: 1. To gain a better understanding of the relationships between these two important public health problems (basic research), 2. To provide evidence-based treatments for survivors of CAN with SUDs and to increase the awareness for the necessity to diagnose CAN in patients with SUDs in counselling and treatment facilities (research on diagnostics and therapy), 3. To improve the systematic evaluation of child welfare among children of parents with SUDs through counselling services and to promote links between addiction services and youth welfare services (prevention research and health services research). In a multidisciplinary approach, the CANSAS network brings together experts in the fields of trauma treatment, epidemiology, basic research, health services research, prevention research as well as addiction services.

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.

The effect of repeated exposure to ethanol on pre-existing fear memories in rats

RATIONALE

There is a high degree of comorbidity between alcohol use disorder and post-traumatic stress disorder (PTSD), but little is known about the interactions of ethanol with traumatic memories.

OBJECTIVES

Using auditory fear conditioning in rats, we asked if repeated exposure to ethanol could modify the retrieval of fear memories acquired prior to ethanol exposure.

METHODS

Following auditory fear conditioning, Sprague-Dawley rats were given daily injections of ethanol (1.5 g/kg) or saline over 5 days. Two days later, they were given 20 trials of extinction training and then tested for extinction memory the following day. In a separate experiment, conditioned rats were given repeated ethanol injections and processed for c-Fos immunohistochemistry following a fear retrieval session.

RESULTS

Two days following the cessation of ethanol, the magnitude of conditioned fear responses (freezing and suppression of bar pressing) was significantly increased. This increase persisted the following day. Waiting 10 days following cessation of ethanol eliminated the effect on fear retrieval. In rats conditioned with low shock levels, repeated exposure to ethanol converted a sub-threshold fear memory into a supra-threshold fear memory. It also increased c-Fos expression in the prelimbic prefrontal cortex, paraventricular thalamus, and the central and basolateral nuclei of the amygdala, areas implicated in the retrieval of fear memories.

CONCLUSIONS

These results suggest that repeated exposure to ethanol may exacerbate pre-existing traumatic memories.

Towards a unitary perspective between post-traumatic stress disorder and substance use disorder. Heroin use disorder as case study

BACKGROUND

Genetic, neurobiological, environmental and psychosocial mechanisms have received considerable attention in exploring the mechanisms that underlie comorbid PTSD and SUD. PTSD and SUD are not necessarily linked by a causal relationship, as the self-medication hypothesis had supposed. They might, in fact, both be caused by a third factor that predisposes these subjects to develop the two disorders (so allowing a unitary perspective).

METHODS

Using a conceptualization of the PTSD spectrum, we studied the PTSD-SUD unitary perspective by testing the correlation between severity of heroin addiction, dose of opioid medication and severity of PTSD spectrum in 82 methadone-treated, heroin-dependent patients.

RESULTS

Canonical correlation analysis (Wilks Lambda=0.125F=1.41 p=0.014), univariate and multivariate comparisons between subgroups, identified on the basis of addiction severity, showed a highly positive correlation between the PTSD spectrum and the severity of heroin addiction. In addition, negative correlations were found between PTSD spectrum severity and methadone dose (r=0.225; p=0.042).

CONCLUSIONS

This strength and breadth of the correlations encourage us to move towards a unified vision of the two disorders.

Intercepting the intergenerational cycle of maternal trauma and loss through mother-infant psychotherapy: a case study using attachment-derived methods

Some mothers who have recently lost a significant attachment figure may become mentally incoherent and sporadically even enter a trancelike, dissociative state. Such states of mind have been shown to predict infant attachment disorganization. Infants born close to the time of a parental loss are at a greater risk for intergenerational trauma. A background of maternal substance abuse is also known to increase such risk. We illustrate by way of a case study how a mother-infant group psychotherapy programme aimed at substance-abusing mothers may help to prevent the transmission of mother's unresolved trauma to the infant. Another goal was to discuss how attachment-derived methods (namely, Adult Attachment Interview, Strange Situation Procedure and the Emotional Availability Scales) may aid in understanding the effects of the intervention.

Stress increases voluntary alcohol intake, but does not alter established drinking habits in a rat model of posttraumatic stress disorder

BACKGROUND

Life-altering anxiety disorders, such as posttraumatic stress disorder (PTSD), can co-occur at high rates with substance use disorders. Alcoholism, compared with other substance use disorders, is particularly common. Rodent studies of acute stress effects on alcohol consumption show that stress can alter ethanol (EtOH) consumption. This study examined voluntary EtOH consumption in male Long-Evans rats that had undergone a stress-enhanced fear learning (SEFL) procedure.

METHODS

Adult Long-Evans rats were exposed to a stress that consisted of 15 inescapable foot-shocks (1 mA, 1 second) known to cause a long-lasting nonassociative enhancement of subsequent fear learning. Control animals received no shock. One day later, animals were placed in a novel and very different context and received a single foot-shock. On day 3, animals were returned to the single shock context and freezing was used as a measure of learned fear. The intermittent access 2-bottle choice (2BC) regimen consisted of 1 bottle of water and 1 bottle of experimental solution, either 19% EtOH or 28.4% sucrose-0.08% quinine, for a 24-hour period, 3 days a week, and all other times 2 water bottles. This regimen lasted until stable levels of experimental solution drinking were reached, at which point the experimental solution was removed for 40 days and then returned to measure the resumption of consumption.

RESULTS

Rats that received stress prior to EtOH consumed significantly more EtOH than control rats before and after reinstatement. Rats that received stress after drinking was established did not consume significantly more EtOH when the drug was returned. Stress had no significant effect on sucrose-quinine drinking, our calorie and taste control for EtOH.

CONCLUSIONS

A single traumatic event sufficient to produce long-lasting enhancement of fear learning increases voluntary EtOH consumption, but does not alter previously acquired EtOH drinking habits or alter the consumption of a calorically equivalent sweet-bitter-tasting solution.

Alcohol Use, Problems, and the Course of Posttraumatic Stress Disorder: A Prospective Study of Female Crime Victims

OBJECTIVE

This study examines whether alcohol use disorder status and consequences of drinking moderate the course of PTSD over the first 6 months following trauma exposure in a sample of female victims of interpersonal violence.

METHODS

Female sexual and physical assault victims (n = 64) were recruited through police, hospital, and victim service agencies. Women completed structured clinical interviews and self-report measures within the first five weeks, three months, and six months post-trauma with 73% retention across all three time points (n = 47). Analyses were conducted using Hierarchical Linear Modeling using alcohol abuse/dependence, peak alcohol use, and consequences during the 30 days prior to assault as moderators of the course of PTSD over time.

RESULTS

Women with alcohol use disorder at baseline had lower initial PTSD symptoms but also less symptom recovery over time than women without alcohol use disorder. This pattern of results was also found for those with high negative drinking consequences during the month prior to the assault. Baseline alcohol use was not found to significantly moderate PTSD course over the 6 months.

CONCLUSIONS

Findings suggest that negative consequences associated with alcohol use may be a risk factor for PTSD. Incorporating assessment of drinking problems for women presenting early post-trauma may be useful for identifying PTSD risk.