Posttraumatic Stress and Substance Use Disorders

A Comprehensive Clinical Handbook

Anka A. Vujanovic, Sudie E. Back, Anka A. Vujanovic, Sudie E. Back

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138208971
• eBook ISBN: 9781315442624
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Posttraumatic Stress and Substance Use Disorders summarizes the state of the field from a biopsychosocial perspective, addressing key domains of interest to clinicians, students, instructors, and researchers.

This book is a valuable resource and reference guide for multidisciplinary practitioners and scientists interested in the evidence-based assessment and treatment of posttraumatic stress and substance use disorders.

Chapters written by leaders in the field cover the latest research on assessment, diagnosis, evidence-based treatments, future directions, and much more.

Part I

Overview

1

PTSD and Substance Use Disorders

A Clinical Overview

Anka A. Vujanovic and Sudie E. Back

Overview

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur (McCauley, Killeen, Gros, Brady, & Back, 2012), presenting a significant challenge to clinical scientists and practitioners. The development of a deeper understanding of this comorbidity is critical, as the co-occurrence of PTSD and SUD presents a clinical and public health concern. The comorbidity is challenging, difficult to treat, and marked by a more costly and chronic clinical course when compared to either disorder alone (McCauley et al., 2012; Mills Teesson, Ross, & Peters, 2006; Schäfer & Najavits, 2007). Individuals with PTSD/SUD comorbidity, relative to those with either disorder alone, tend to manifest worse treatment adherence, less improvement in symptomatology during treatment, more legal problems, increased risk for experiencing violence, poorer social functioning, more severe physical health problems, and higher rates of suicide attempts (Foa & Williams, 2010; McCauley et al., 2012). Moreover, PTSD, including subclinical PTSD (Norman, Tate, Anderson, & Brown, 2007), is associated with strong drug cravings (Coffey et al., 2002; Saladin et al., 2003) and withdrawal symptoms (Boden, Babson, Vujanovic, Short, & Bonn-Miller, 2013), as well as a greater tendency to use substances to alleviate negative mood states (Back, Brady, Jaanimägi, & Jackson, 2006; Chilcoat & Breslau, 1998; Jacobsen, Southwick, & Kosten, 2001).

The goal of this volume, therefore, is to provide an up-to-date clinical resource for clinicians, students, teachers, and researchers interested in learning more about PTSD/SUD comorbidity. This book reviews clinically relevant literature on PTSD/SUD and provides a consolidated summary of our current understanding of etiological pathways, phenomenology, and clinical correlates, as well as “best practice” avenues for assessment and treatment. This first chapter aims to: (1) briefly review the prevalence of trauma and PTSD among SUD populations, and the prevalence of substance use and SUD among individuals who have experienced trauma or have PTSD; (2) summarize common past clinical practices for PTSD/SUD populations; (3) highlight current evidence-based trends and promising clinical avenues; and (4) delineate roads for future clinical and empirical exploration.

Prevalence Rates

The majority of the general population will experience a traumatic life event (e.g., natural disaster, motor vehicle accident, sexual assault), as defined by the DSM-5 (Kilpatrick et al., 2013), and approximately 6–8% of the general population will develop PTSD at some point during their lifetime. Notably, subclinical PTSD and clinical (i.e., diagnostic) PTSD are associated with similar rates of comorbidity and functional impairment (Pietrzak, Goldstein, Southwick, & Grant, 2011), underscoring the clinical significance of considering subclinical PTSD in conversations about PTSD/SUD (McLaughlin et al., 2015; Ruglass et al., 2017). Among individuals with PTSD, the prevalence of co-occurring SUD, including alcohol use disorder (AUD), is estimated to be as high as 52%, substantially higher than the prevalence of lifetime SUD in the general population, which is approximately 35% (Kessler, Chiu, Demler, & Walters, 2005; Mills et al., 2006; Pietrzak et al., 2011).

Among adults with SUD, rates of trauma exposure are as high as 95% (Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995; Reynolds et al., 2005), depending on the sample and substance class studied. Among individuals with SUD, the prevalence of lifetime PTSD is estimated to be between 26% and 60%, while the prevalence of current PTSD is estimated to be 15–42% (Back et al., 2000; Brady, Back, & Coffey, 2004; Dragan & Lis-Turlejska, 2007; Driessen et al., 2008; Jacobsen et al., 2001; Mills et al., 2006; Reynolds, Hinchliffe, Asamoah, & Kouimtsidis, 2011; Reynolds et al., 2005; Schäfer et al., 2010).

Notably, the aforementioned prevalence rates are significantly higher among treatment-seeking populations (McCauley et al., 2012). The considerable range in published prevalence rates is largely due to variability across populations, clinical settings, and measures employed to assess PTSD and SUD. Relatedly, changes in diagnostic criteria for PTSD and SUD (Henschel, Jeffirs, Augur, & Flanagan, this volume) may influence changes in prevalence rates over time. Taken together, approximately one in every two individuals with PTSD or SUD will meet criteria for the other disorder. Thus, PTSD/SUD represents a meaningful and common comorbidity that is frequently encountered in clinical settings.

Historical Review of PTSD/SUD Treatment

Several clinical models of care for PTSD/SUD have been adopted at different points in history. Until relatively recently, the most common treatment model employed across settings was the sequential model of care, which posits that the SUD needs to be treated first and trauma-focused interventions should be deferred until sustained abstinence, as defined by the clinical provider or treatment setting, from substance use is achieved. In the sequential model, interventions for SUD and PTSD were typically provided by different clinicians, usually across separate treatment clinics or agencies. Despite little empirical support, the sequential model continues to be maintained in practice by several factors. First, some clinicians may be concerned that continued substance use during PTSD treatment will interfere with the cognitive or emotional processing of the trauma, resulting in little or no reduction in PTSD severity. Second, others purport that engaging in PTSD treatment will serve to maintain or increase ongoing substance use, or lead to relapse following abstinence due to insufficient or compromised emotion regulation skills (Souza & Spates, 2008). Third, clinical providers are often trained either in the assessment and treatment of PTSD or SUD but rarely both. Thus, preference for the sequential model may be driven by pragmatic issues, such as insufficient training or limited familiarity with comorbid populations. Relatedly, many clinical settings specialize in the treatment of PTSD or SUD, and thus, services may not be available for the treatment of the co-occurring condition. Finally, clinical awareness of the prevalence and complexity of PTSD/SUD comorbidity has been a relatively recent development within the past 20 years. With greater awareness and empirical scrutiny came the realization that individuals with PTSD/SUD are at increased risk for relapse to substance use for as long as the PTSD remains untreated (e.g., McCauley et al., 2012).

Concurrent and integrated models of care emerged as a result of the challenges inherent in the sequential model, including high relapse rates and limited care coordination between providers. Concurrent models of care generally offer treatment for PTSD and SUD at the same time by different clinicians. For example, a client may be in individual PTSD treatment with one provider and in SUD treatment with another at the same time. As another example, individuals in residential treatment for SUD may be offered weekly PTSD treatment in the form of individual or group therapy. Integrated models of care underscore the importance of the intersection of PTSD and SUD and thus indicate the treatment of both disorders simultaneously by the same clinician. This model of care is informed largely by the self-medication theory (Khantzian, 1999; Reed, Anthony, & Breslau, 2007), which purports that substance use is driven in part by an attempt to ameliorate (i.e., “medicate”) symptoms of PTSD. According to the integrated model, providing psychoeducation regarding the interplay of PTSD/SUD and targeting PTSD symptoms alongside SUD may improve long-term outcomes.

The majority of individuals with PTSD/SUD continue to only receive SUD treatment (Najavits, Sullivan, Schmitz, Weiss, & Lee, 2004; Young, Rosen, & Finney, 2005), contrary to most clients’ preferences (Back, Brady, Jackson, Salstrom, & Zinzow, 2005; Brown, Stout, & Gannon-Rowley, 1998; Brown et al., 1998). Adults in treatment for SUD are often not assessed for PTSD and not offered trauma-informed interventions, and vice versa (Bujarski et al., 2016; Mills et al., 2006; Reynolds et al., 2005). Therefore, this volume offers a review of evidence-based assessment approaches for PTSD in the context of SUD (Dutra & Marx, this volume) as well as assessment of SUD in individuals with PTSD symptoms (Barrett, Deady, Kihas, & Mills, this volume). More well-constructed bridges between science and practice are thus imperative in order to deliver and implement evidence-based practices. In addition, greater attention to innovative dissemination and implementation efforts (Dworkin, Lehavot, Simpson, & Kaysen, this volume) is imperative to increase the reach of the “treatments that work” to ethnically diverse and underserved communities, including rural, low-income, non-English-speaking, and inner-city populations. Given the diversity of American society, it is important also to consider applying a cultural lens to PTSD/SUD treatment and to adapt extant evidence-based interventions for cultural subgroups and/or to develop novel specialized interventions for specific populations (Washington & Brown, this volume).

Perhaps most importantly, despite the scientific and clinical strides of the past 20 years, there continues to be no consensus regarding “best practice guidelines,” and most treatment-seeking individuals with PTSD/SUD are passed between PTSD and SUD treatment services with little care coordination (Roberts, Roberts, Jones, & Bisson, 2015). Recent systematic reviews and meta-analyses (Roberts et al., 2015; Simpson, Lehavot, & Petrakis, 2017) have found that interventions that integrate exposure-based PTSD treatment with behavioral SUD treatment are recommended, but that there are perhaps “no wrong doors” (Simpson et al., 2017). That is, individuals with PTSD/SUD may benefit from a variety of treatment options, including standard SUD treatment.

Current Treatment Trends

Several evidence-based PTSD/SUD interventions are currently available. Leading interventions are profiled in this volume and include cognitive-behavioral individual or group-based approaches as well as pharmacotherapies. Seeking Safety presents the most well-studied and widely disseminated PTSD/SUD intervention (Litt, Cohen, & Hien, this volume). Emerging evidence-based PTSD/SUD interventions for adults with considerable promise also include (a) Concurrent Treatment of PTSD and SUD using Prolonged Exposure (COPE; Back, Killeen, & Brady, this volume), which integrates prolonged exposure therapy for ...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• List of Tables
• List of Figures
• List of Contributors
• Acknowledgements
• PART I Overview
• PART II Assessment and Diagnosis
• PART III Treatment Approaches
• PART IV Future Directions for Treatment
• Index