Stuck in a Moment in Time: PTSD and Substance Use Disorders

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1 Stuck in a Moment in Time: PTSD and Substance Use Disorders Dr Glenys Dore. May 2012 Northern Sydney Drug & Alcohol Service

2 NDARC Integrated treatment studies PTSD & illicit drugs PTSD & alcohol Recruitment

3 Prevalence PTSD, depression, suicidality inpatients with SUD s 9 months 253 patients Dr Glenys Dore Dr Katherine Mills Robin Murray Professor Maree Teesson Philipa Farrugia Drug & Alcohol Review 2012:31:

4 PTSD: DSM-IV EXPOSURE TO A TRAUMATIC EVENT in which both the following were present: the person experienced, witnessed or was confronted with an event/s that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others the person s response involved intense fear, helplessness or horror

5 Trauma situations 1. Seriously physically attacked or assaulted 2. Threatened with a weapon, held captive, kidnapped 3. Involved in life-threatening car accident 4. Involved in fire, flood, natural disaster 5. Witnessed someone badly injured or killed 6. Rape 7. Sexual molestation 8. Tortured or victim of terrorists 9. Direct combat in war situation 10. Person s response involved intense fear, helplessness or horror

6 Trauma Screening Questionnaire (TSQ) Please indicate (Yes/No) whether or not you have experienced any of the following at least twice in the past month: 1. Upsetting thoughts or memories about the event that have come into your mind against your will. 2. Upsetting dreams about the event. 3. Acting or feeling as though the event were happening again. 4. Feeling upset by reminders of the event. 5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event. 6. Difficulty falling or staying asleep. 7. Irritability or outbursts of anger. 8. Difficulty concentrating. 9. Heightened awareness of potential dangers to yourself and others. 10. Being jumpy or being startled at something unexpected. 6

7 Shaun 33 yrs, single, labourer Detox Unit admission Heroin withdrawal Booked in rehab

8 Shaun: Day 2 Routine review Precipitant for heroin use Traumatic event 5 years ago Unable to move on

9 Shaun: Day 2 Left party drunk Short cut home Through the park Raped at knifepoint Assailant much smaller Unable to run/react

10 PTSD ( TRAP ) Traumatic event: Re-experiencing or re-living the trauma Avoidance and Numbing Physical arousal/tension

11 Re-experiencing the trauma recurrent & intrusive recollections of the event, including images, thoughts or perceptions recurrent nightmares acting or feeling as if the trauma were recurring dissociative flashbacks sense of reliving the experience illusions hallucinations

12 Re-experiencing the trauma With exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event: physiological reactivity intense psychological distress

13 Avoidance and Numbing Avoid reminders of trauma thoughts, feeling, conversations activities, places, people unable to recall key aspects

14 Avoidance and Numbing Emotional withdrawal: reduced involvement in sig. activities sense of detachment from others restricted range of affect sense of foreshortened future

15 Physical arousal/tension hypervigilant ( on guard ); exaggerated startle response; irritability & angry outbursts; poor concentration; difficulty falling or staying asleep

16 Treatment approaches for trauma symptoms

17 Comorbidity resource Katherine L Mills Mark Deady Heather Proudfoot Claudia Sannibale Maree Teesson Richard Mattick Lucy Burns Funded by the Australian Government Department of Health and Ageing Available at

18 Do s & Don ts

19 DO: Screen for traumatic events, PTSD with SUD s AVOIDANCE part of disorder: if you don t ask they may not say routine questions self-report screener may be easier; complete with staff member present

20 DO: Provide a sense of control Clearly explain reasons for asking: trauma common with SUD s: 80-90% PTSD common: 45% (our study) vs 7.8% lifetime (ECA study) substance use often way of coping symptoms often during withdrawal addressing trauma can be effective

21 DO: Provide a sense of control Seek patient s permission to ask Advise no need to discuss or provide any detail if they don t want to Advise of restrictions on confidentiality mandatory reporting children at risk serious indictable offenses

22 DO: Provide specific examples of traumatic events: e.g. MVA, sexual assault, rape refer to the trauma by name less likely to underreport

23 DO: Discuss substance use as an adaptive response reduces the client s guilt and shame provides a framework to develop new skills to better cope with symptoms Praise for resilience in the face of adversity even if past ways of coping are causing problems (e.g. substance use).

24 DO: Display a comfortable, sensitive, non judgemental attitude Praise for having the courage to talk about what happened Normalise responses and validate feelings (including difficult discussing)

25 DO: Validate! Validate!! Validate!!!

26 Don t Interrupt or abruptly end session Rush or force the person to reveal information about the trauma Engage in an in-depth discussion of the trauma unless you are trained in trauma responses

27 Discuss common reactions to trauma Fight/flight/freeze Guilt/shame PTSD symptoms Depression Using alcohol/drugs to cope Loss of control

28 Discuss common reactions to trauma Fight/flight/freeze Guilt/shame PTSD symptoms Depression Using alcohol/drugs to cope Loss of control

29 Re-experiencing Memories too painful to process avoided pushed away Memories, nightmares return as trauma is unfinished business the mind is wanting to process and make sense of them and move on

30 Avoidance and Numbing The patient is in survival mode Avoidance: a way to keep safe from further danger which still feels present The individual may feel safe but is isolated and withdrawn from life (Jan Ewing workshop June 2008)

31 Physical arousal/tension Keeps the patient alert & prepared for the presence of danger know where the exits are; back to the wall need to be able to see and monitor everything The threat detector is so strong, the slightest whiff of a threat results in hyperarousal (Jan Ewing 2008)

32 PTSD symptoms often increase during withdrawal No longer masked by D & A use Autonomic hyperactivity in withdrawal exacerbates hyperarousal symptoms Educate patients about likely increase in symptoms Provide tools/strategies to manage symptoms

33 Strategies to manage PTSD symptoms Don t hesitate to medicate Withdrawal medications Quetiapine PTSD: SSRI s, SNRI s, mirtazapine

34 Strategies to Manage PTSD Symptoms

35 Strategies to manage PTSD symptoms Contain & reduce symptoms: Progressive muscle relaxation Breathing techniques Visualisation and imagery Grounding e.g. mindfulness

36

37

38 What about longer term treatment?

39 Gold standard PTSD: exposure Imaginal exposure Patient asked to imagine feared images or situations Used when not possible or safe to directly confront a feared situation e.g. held up at knife point in a supermarket. Helps patient process traumatic memories in a safe & controlled way

40 Gold standard PTSD: exposure In vivo exposure: direct confrontation of feared objects, activities, or situations by a patient. Supermarket knife attack list of feared situations (graded hierarchy) set in vivo task at bottom of list stay in feared situation until fear 50% or less

41 Gold standard PTSD: exposure Traditionally considered inappropriate with SUD: fear >emotions trigger relapse impaired cognitions SUD impair ability for imaginal exposure belief extended recovery needed Teesson & Mills Workshop 2006

42 The first randomised controlled trial of exposure therapy among those with SUDs Katherine L Mills 1, Maree Teesson 1, Emma Barrett 1, Sabine Merz 1, Julia Rosenfeld 1, Philippa Farrugia 1, Claudia Sannibale 1, Sally Hopwood 2, Amanda Baker 3, Sudie Back 4, Kathleen Brady 4 1 National Drug and Alcohol Research Centre, University of New South Wales 2 Traumatic Stress Clinic, Westmead Hospital 34 Centre for Brain and Mental Health Research, University of Newcastle 4 Department of Psychiatry, Medial University of South Carolina

43 COPE v. II Modified version of CTPSD: Concurrent Treatment with Prolonged Exposure version II COPE v2; Mills et al 2007

44 COPE Treatment components CBT for substance use (Sessions 1-4 and throughout) Psychoeducation relating to both disorders and their interaction (Sessions 1-4) In vivo exposure (Sessions 5-12) Imaginal exposure (Sessions 6-12) Cognitive therapy for PTSD (Sessions 8-12) Review, after care plan, termination (Session 13)

45 Randomised controlled trial N = Treatment (53%) (receive COPE) 48 Control (47%) (assessment only) Both groups may receive treatment as usual for their substance use in the community (e.g., detox, residential rehabilitation, maintenance pharmacotherapies, counselling etc)

46 Conclusion Across the 9 month follow-up period: Both groups evidenced improvements in their Substance use Severity of dependence PTSD symptoms Depression Anxiety General mental health THEY DID NOT GET WORSE!

47 Conclusion Participants randomised to COPE demonstrated: significantly greater improvements in PTSD symptoms particularly avoidance and hyperarousal symptoms These findings provide evidence in support of treating PTSD among people with SUDs using COPE

48

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