The Link Between Trauma and Substance Misuse: Thinking about the Unthinkable

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1 The Link Between Trauma and Substance Misuse: Thinking about the Unthinkable Dr Lisa Reynolds Greater Glasgow and Clyde NHS Trauma Service: The Trauma and Homelessness Team

2 Aims of Discussion Definition of Trauma Prevalence and Characteristics of comorbid population The link between Trauma and Substance Misuse: Why might people with Trauma consequences use substances? Questions

3 Definitions of Trauma Type 1 Trauma Out of the Blue Adults/ Children Unexpected Type 1 Trauma Time Bound Shock Discrete Incident

4 Type 1 Trauma: Consequences PTSD Post Traumatic Stress Disorder ICD-10 Following an exceptionally threatening /catastrophic event Re-experiencing : Flashbacks, Intrusive thoughts Avoidance of triggers to traumatic memories Emotional numbing Hyper arousal

5 PTSD McFarlane motor vehicle accident victims with no past psychiatric history 6 month and 18 month follow up 42% no disorder 19% PTSD, 17% major depression, 37% anxiety disorder, 22% some other disorder PTSD Other Anxiety Depressio n

6 Defining Complex Trauma Complex trauma is defined as long term, interpersonal abuse occurring on multiple occasions and often beginning early in life (Herman, 1992) Complex trauma results from exposure to severe stressors that (1) are repetitive and prolonged, (2) involve harm or abandonment by caregivers or other ostensibly responsible adults and (3) occur at developmentally vulnerable times in the victims life (Ford and Courtois, 2009)

7 Impact of Complex Trauma PTSD COMPLEX PTSD DESNOS Reexperiencing Avoidance Emotional Numbing Hyper arousal Changes in mind, emotions, body and relationships Severe problems with dissociation, emotion dysregulation, somatic distress, relational alienation Alterations in: Affect and impulse regulation Biological self regulation Attention and Consciousness Perception of the perpetrator/ others Self perception Relationships System of meaning

8 Co-morbidity of Trauma and Substance Misuse Prevalence rates of co-morbid PTSD and Substance abuse range from 19-35%, co-morbid alcohol abuse 36-52% (Breslau and Davies, 1992; Kessler et al. 1995) In Substance Use Disorder populations rates of 30-58% have been reported for lifetime PTSD and 20-38% for current PTSD (Triffelman et al. 1995; Najavits et al. 1998) Reynolds et al. (2005) Found a prevalence rate of 38.5% for current and 51.9% for lifetime PTSD a substance misuse population. Also found a high number of traumatic experiences reported by this group indicating that trauma is common within this population Using PTSD within research because of difficulties diagnosing Complex Trauma

9 Characteristics of this Co-Morbid Population Substance misuse clients with co-morbid PTSD reported Greater impairment in their social, occupational and family responsibilities More distress associated with the target trauma and with memories of the target trauma More frequent occurrence of memories associated with the target trauma More distress associated with them since the cessation of drug use Than non-substance misusing PTSD group (Reynolds 2005)

10 Why Is Substance Misuse Intrinsically Linked to Trauma? Risk Factors for Trauma Mental Health Consequences of Complex Trauma Psychological Difficulties Associated with Complex Trauma Complex Relationship Between Complex Trauma and Substance Misuse

11 Risk Factors for Trauma Parental Substance Misuse Impact on Attachment / Bonding /Availability of mum Could be further exacerbated if mum /dad have history of trauma Increased vulnerability to trauma/ abuse and retraumatisation -Mum/Dad unavailable/ unable to protect -Increase of risky others having access to child Modelling of unhelpful coping /poor affect regulation Increased risk of being removed from parents / placed into care system Increased access to substances

12 Risk Factors for Trauma: Substance Misuse Drug use increases the risk of victimisation. Kilpatrick et al.(1997) demonstrated that Drug use in previously non-victimised women was associated with an increased risk of new assault. This risk was over and above effects of age, race and education Reciprocal relationship was observed in that a new assault in women who had not previously used drugs was associated with an increased risk of substance use. Cottler et al.1992 found the odds of drug users being assaulted were 5.06 times greater than nonusers

13 Mental Health /Psychological Consequences of Complex Trauma: Alterations in Perception of Others and Relationship with Others Power and Control Imbalance Control power loss with substances / gain with substances Substances used to control : sexual exploitation/ domestic abuse Social Phobia

14 Mental Health /Psychological Consequences of Complex Trauma: Affect Regulation Difficulties Impact of Trauma on Attachment Development Extremely Distressing affect changes Poorly developed coping skills / self-soothing / Mindfulness Specific Mental Health Affect /Mood Disorders Anxiety Depression Anger Specific physiological effects of different substances as self-medication however, substances lead to symptoms which mimic / exacerbate original symptoms Alcohol withdrawal and anxiety symptoms / mood Cannabis withdrawal and sleep disturbance Long-term benzodiazepine use and anxiety Leading to vicious circle

15 Mental Health /Psychological Consequences of Complex Trauma: PTSD Symptoms Intrusive /Reliving Experiences including sleep disorders: Alcohol and Benzodiazepines associated with memory impairments, supporting the idea that people may use them to dampen down or forgetting traumatic memories Increased Arousal (Khantzian, 1985) Avoidance Immediate effects of specific drugs especially depressants and Analgesics Implications of using stimulants Impaired memory and concentration, sleep disturbance, anxiety, irritability, vivid dream and intrusive images and flashbacks are recognised features of PTSD but may also accompany drug withdrawal.

16 Mental Health /Psychological Consequences of Complex Trauma: Dysregulation in Consciousness Dissociation Survival /Coping strategy Protects individual from event but is then used to protect individual from re-experiencing symptomatology. Attempt to recreate / enhance / generalise effects of dissociation Similar to dissociation and DSH, substance misuse initially may work very well but leads to further difficulties, exacerbates trauma symptoms and interferes with treatment

17 Mental Health /Psychological Consequences of Complex Trauma: Dysregulation in Behavioural Self - Management Dangerous / Impulsive Risk Taking Sensation Seeking Behaviours 20% of substance misusers use substances purely with the expectation of having a better time / enhancing a pleasurable experience Polydrug use and dangerous drug taking practices. Implications on safety phase Harm Reduction?

18 Mental Health /Psychological Consequences of Complex Trauma: Alterations in Self Perception Self perception can change following abuse and trauma leading to Learned Helplessness Expectations / I deserve Perpetuating role of substance misuse on negative self perception I m useless I am an addict

19 Mental Health /Psychological Consequences of Complex Trauma: Alterations in Somatic Functioning Pain and analgesic use Learned belief that they cannot tolerate even routine pain tolerance built up to normal dose medications Drug users often become highly educated about drug effects leading to self medication and sometimes high risk poly substance misuse

20 Mental Health /Psychological Consequences of Complex Trauma: Alterations in Systems of Meaning What's the point /Hopelessness leading to substance misuse Searching for more / new meanings Live Life for today philosophy

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