Substance abuse and post-traumatic stress disorder comorbidity

doi:10.1016/0376-8716(94)90110-4

Drug and Alcohol Dependence

Volume 35, Issue 1, March 1994, Pages 51-59

https://doi.org/10.1016/0376-8716(94)90110-4 Get rights and content

Abstract

This article reviews the extant literature on substance abusers with and without a comorbid diagnosis of post-traumatic stress disorder (PTSD) and reveals the discontinuity between clinical lore and empirical research. Included is an overview of PTSD-substance abuse theoretical models and comorbidity prevalence rates, as well as an evaluation of the comparative data on treatment outcome and psychosocial factors, such as coping skills, for PTSD versus non-PTSD substance abusers. In addition, we discuss the controversy surrounding sequential versus simultaneous treatment approaches for such ‘dually-diagnosed’ patients. We conclude by identifying gaps in current knowledge about the nature and impact of PTSD on substance abuse treatment outcome and outlining needs for future research.

References (88)

K. Bollerud
A model for the treatment of trauma-related syndromes among chemically dependent in-patient women
J. Subst Abuse Treat.
(1990)
J.A. Fairbank et al.
Flooding for combat-relaled slress disorders: Assessment of anxiely reduction across traumatic memories
Behav. Ther.
(1982)
L. Hyer et al.
Hidden PTSD in substance abuse in-patients among Vietnam veterans
J. Subst. Abuse Treat.
(1991)
J.R. Ito et al.
Predicting drinking outcome: Demography, chronicity, coping and aftercare
Addict. Behav.
(1990)
J.M. Jelinek et al.
Post-traumatic stress disorder and substance abuse in Vietnam combat veterans: Treatment problems, strategies, and recommendations
J. Subst. Abuse Treat.
(1984)
A. Kuhne et al.
Efficacy of chemical dependency treatment as a function of combat in Vietnam
J. Subst. Abuse Treat.
(1986)
J.M. Schnitt et al.
Alcoholism treatment of Vietnam veterans with post-traumatic stress disorder
J. Subst. Abuse Treat.
(1984)
L. Sjoberg et al.
Coping strategies and relapse in alcohol abuse
Drug Alcohol Depend.
(1985)
D.D. Blake et al.
A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1
Behav. Ther.
(1990)

B.M. Booth et al.

Comorbid mental disorders in patients with AMA discharges from alcoholism treatment

Hosp. Commun. Psychiatry

(1992)

P.A. Boudewynsc et al.

Chronic combat-related concurrent substance abuse: Implications for treatment of this frequent ‘dual diagnosis.’

J. Traumatic Stress

(1991)

N. Breslau et al.

Traumatic events and post-traumatic stress disorder in an urban population of young adults

Arch. Gen. Psychiatry

(1991)

D. Brief et al.

Psychopathology in male-substance abusers: Relationship to drug of choice and early trauma

T. Brinson et al.

Alcoholism and post-traumatic stress disorder among combat Vietnam veterans

Alcohol. Treat. Q.

(1988)

D.S. Cannon et al.

Correspondence between MMPI PTSD measures and clinical diagnosis

J. Personality Assess.

(1987)

H. Cappell et al.

Alcohol and tension reduction. An update on research and theory

E.F. Chaney et al.

Skill training with alcoholics

J. Consult. Clin. Psychol.

(1978)

D.S. Charney et al.

Psychobiologic mechanisms of posttraumatic stress disorder

Arch. Gen. Psychiatry

(1993)

J.J. Conger

The effects of alcohol on conflict behavior in the albino rat

J. Stud. Alcohol

(1951)

L.B. Cottler et al.

Post-traumatic stress disorder among substance users from the general population

Am. J. Psychiatry

(1992)

R.C. Cronkite et al.

Determinants of post-treatment functioning of alcoholic patients: A conceptual framework

J. Consult. Clin. Psychol.

(1980)

L. Dixon et al.

Acute effects of drug abuse in schizophrenic patients: Clinical observations and patients' self-reports

Schizophrenia Bull.

(1990)

L. Dixon et al.

Drug abuse in schizophrenic patients: Clinical correlates and reasons for use

Am. J. Psychiatry

(1991)

K.A. Druley et al.

Post-traumatic stress disorder in World War II and Korean combat veterans with alcohol dependency

C.D. Emrick et al.

Assertions regarding effectiveness of treatment for alcoholism: Fact or fantasy

Am. Psychol.

(1983)

J.A. Fairbank et al.

Treatment of post-traumatic stress disorder: Evaluating outcome with a behavioral code

Behav. Modification

(1983)

J.A. Fairbank et al.

Patterns of appraisal and coping across different stressor conditions among former prisoners of war with and without post-traumatic stress disorder

J. Consult Clin. Psychol.

(1991)

D. Finkelhor et al.

Sexual abuse and its relationship to later sexual satisfaction, marital status, religion, and attiludes

J. Interpersonal Violence

(1989)

E.B. Foa et al.

Behavioral/cognilive conceptualizations of post-traumatic stress disorder

Behav. Ther.

(1989)

M.J. Friedman

Biological approaches to the diagnosis and treatment of post-traumatic stress disorder

J. Traumatic Stress

(1991)

D. Goodwin et al.

Psychiatric diagnosis

(1984)

J.R. Graham

MMPI-2: Assessing personality and psychopathology

(1990)

B.L. Green et al.

Long-term coping with combat stress

J. Traumatic Stress

(1988)

B.L. Green et al.

Multiple diagnosis in post-traumatic slress disorder: The role of war stressors

J. Nerv. Ment. Dis.

(1989)

J. Helzer et al.

Co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment

J. Stud. Alcohol

(1988)

J.E. Helzer et al.

Post-traumatic stress disorder in the general population: Findings of the epidemiological catchment area survey

N. Engl. J. Med.

(1987)

T.M. Keane et al.

Mississippi Scale for Combat Related PTSD: Three studies in reliability and validity

J. Consult. Clin. Psychol.

(1988)

T.M. Keane et al.

Imaginai flooding in the treatment of a post-traumatic stress disorder

J. Consult. Clin. Psychol.

(1982)

T.M. Keane et al.

Empirical development of an MMPI subscale for the assessment of combat-related post-traumatic stress disorder

J. Consult. Clin. Psychol.

(1984)

T.M. Keane et al.

Comorbidity in post-traumatic stress disorder: An analysis of community and clinical studies

J. Appl. Soc. Psychol.

(1990)

T.M. Keane et al.

Post-traumatic stress disorder: Evidence for diagnostic validity and methods of psychological assessment

J. Clin. Psychol.

(1987)

E.J. Khantzian

The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence

Am. J. Psychiatry

(1985)

E.J. Khantzian

Self-regulation and self-medication factors in alcoholism and addictions: Similarities and differences

Cited by (219)

Could immutability of an addiction be regarded as due to a post-traumatic disorder in an assessment of body injury?
2023, Annales Medico-Psychologiques
Dans le cadre de l’examen psychiatrique des dommages d’une victime, la recherche d’un lien d’imputabilité entre un événement, un syndrome post-traumatique et des symptômes d’addiction est particulièrement difficile. Nous tentons de clarifier les problèmes liés au raisonnement médico-légal en psychiatrie.
Nous effectuons une revue de la littérature sur deux points. Le premier concerne les notions d’imputabilité, de causalité médicale et de causalité juridique. Le deuxième porte sur les liens entre des conduites addictives et des symptômes traumatiques. Via PubMed et Ascodocpsy, avec les mots clefs suivants : « Substance use disorder in patient with post-traumatic stress disorder ». Dans le champ psychodynamique avec la notion de « traumatophilie ».
1/Le raisonnement juridique rentre dans une démarche rétrospective et recherche l’attribution sociale d’une responsabilité pénale, civile ou administrative. Il est en contradiction avec le raisonnement médical qui vise un projet de soins tourné vers l’action, l’avenir et une possible guérison. 2/Les critères d’imputabilité sont issus d’une médecine d’organe et sont marqués par un modèle lésionnel d’organe. Ils ne sont pas pertinents pour la psychiatrie. 3/Les liens entre le traumatisme et l’addiction sont complexes car il existe une influence réciproque entre l’addiction et l’état de stress post-traumatique : la persistance de l’un favorise la rechute ou l’aggravation de l’autre. Sur un plan statistique, les études montrent une association franche entre des troubles addictifs et des troubles psycho-traumatiques. Les patients qui présentent une comorbidité ESPT/addiction ont par rapport à un ESPT isolé, une évolution plus péjorative surtout si cette comorbidité est associée à des antécédents d’abus durant l’enfance, des maltraitances, une pathologie antérieure, la prise de cocaïne et d’opiacés, un faible soutien par les proches. Quatre modèles psychopathologiques font références : le modèle de risque élevé de trauma, le modèle de vulnérabilité partagée, le modèle de susceptibilité, le modèle de l’automédication. Sur un plan psychodynamique, l’addiction peut se modéliser comme une tentative d’anesthésie psychique, de contrôle et de liaison des angoisses traumatiques.
Pour clarifier le raisonnement médico-légal en psychiatrie portant sur l’imputabilité d’un événement sur des symptômes psycho-traumatiques et des symptômes addictifs, nous proposons d’assumer les spécificités de la maladie mentale. Les maladies mentales sont des maladies fonctionnelles. Il faut donc chercher des modalités de liaison, et non de lésion, entre différents facteurs psychiques. L’addiction est à envisager systématiquement comme un facteur comorbide d’un syndrome psychotraumatique. Entre une addiction et un ESPT : la persistance de l’un favorise la rechute ou l’aggravation de l’autre. Le lien d’imputabilité nous apparaît intéressant à explorer selon les hypothèses développées dans les modèles de comorbidité somatoformes ou bipolaires. Nous proposons plusieurs questions-types qui peuvent aider à la poursuite d’un raisonnement clinique autour de l’imputabilité des troubles.
In the context of the psychiatric examination of the damage of a victim, the research for a link of imputability between an event, a post-traumatic syndrome and symptoms of addiction is specially difficult. We attempt to clarify issues related to forensic thinking in psychiatry.
We carry out a review of the literature on two points: The first one concerns the notions of imputability, medical causality and legal causality. The second one concerns the links between addictive behaviors and traumatic symptoms. Via PubMed and Ascodocpsy, with the following keywords: “Substance use disorder in patient with post-traumatic stress disorder”. In the psychodynamic field with the notion of “traumatophilia”.
1/The legal reasoning is part of a retrospective approach and seeks the social assignment of criminal, civil or administrative responsibility. It contradicts the medical reasoning which aims for a care project focused on action, the future and a possible cure. 2/Imputability criteria come from organ medicine and are marked by an organ lesion model. They are irrelevant to psychiatry. 3/The links between trauma and addiction are complex because there is a reciprocal influence between addiction and post-traumatic stress disorder: the persistence of one promotes the relapse or worsening of the other one. On a statistical level, the studies show a clear link between addictive disorders and psycho-traumatic disorders. Patients with PTSD/addiction comorbidity have, compared to isolated PTSD, a more pejorative evolution, especially if PTSD/addiction is associated with a history of childhood abuse, mistreatment, previous pathology, cocaine use and drug abuse opiates, low support by relatives. Four psychopathological models are referred to PTSD/addiction: the high risk of trauma model, the shared vulnerability model, the susceptibility model, the self-medication model. On a psychodynamic level, addiction can be modeled as an attempt at psychic anesthesia, control and binding of traumatic anxieties. On the neurobiological level, the reference models are based on the hypothalamic-pituitary and noradrenergic system, the opioid systems, NMDA and GABA.
To clarify the medico-legal reasoning in psychiatry relating to the imputability of an event on psycho-traumatic symptoms and addictive symptoms, we propose to assume the specificities of mental illness. Mental illnesses are functional illnesses. It is therefore necessary to look for modalities of connection, and not of lesion, between different psychic factors. Addiction should be systematically considered as a comorbid factor of a psychotraumatic syndrome. Between an addiction and PTSD: the persistence of one favors the relapse or worsening of the other. The imputability link seems interesting to us to explore according to the hypotheses developed in the somatoform or bipolar comorbidity models. We suggest several standard questions that may help in the pursuit of clinical reasoning around the imputability of disorders. Is the traumatic disorder primary and the addiction sequel? Is addictive behavior primary and after effects disorders? Are the two disorders primary and independent? Are the two disorders the outcome of the same underlying cause? Is the traumatic disorder altered by the addiction? Are the traumatic disorder and the addictive disorder combined to form a neopathology? Is addiction a symptom of traumatic disorder? Does the addiction bring out the traumatic disorder? Is the addiction an attempt to self-medicate for the traumatic disorder? Do addiction and traumatic disorder share common risk factors? Circular causality model: are addiction and traumatic disorder mutually reinforcing?
Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis
2021, Journal of Anxiety Disorders
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.
Implications of posttraumatic growth for the treatment of comorbid substance abuse among survivors of traumatic experiences
2021, Journal of Substance Abuse Treatment
Research suggests that individuals treated for substance use disorders are not routinely assessed for post-traumatic stress disorder (PTSD) symptomatology despite high rates of comorbidity. One area of research that has been overlooked in theory, research, and practice on the comorbidity of substance use disorders and PTSD is the study of post-traumatic growth. The purpose of the current study is to explore the relevance of post-traumatic growth for the treatment of comorbid substance use disorders among individuals suffering from traumatic stress or PTSD.
A sample of 256 adults who survived the 2010 earthquake in Haiti completed measures of coping and the Posttraumatic Growth Inventory (PTGI). The study regressed a measure of substance use coping on the scores on the subscales of the Posttraumatic Growth Inventory adjusting for PTSD symptoms, general coping, and religious coping.
The findings suggest that one PTGI subscale, appreciation of life, was a statistically significant predictor of substance use coping among trauma survivors.
The principles of post-traumatic growth may have clinical implications for comorbid substance use among survivors of traumatic events. This study provides a path forward in efforts to create rapprochement between basic research and clinical services in the treatment of comorbid substance use in trauma survivors.
Trauma Informed Guilt Reduction (TrIGR) therapy for guilt, shame, and moral injury resulting from trauma: Rationale, design, and methodology of a two-site randomized controlled trial
2021, Contemporary Clinical Trials
Guilt, shame, and moral injury (MI) are common reactions following exposure to traumatic events and are associated with greater severity of several mental health problems, including posttraumatic stress disorder (PTSD), depression, increased risk of suicidal ideation and poorer psychosocial functioning. Trauma-Informed Guilt Reduction (TrIGR) is a transdiagnostic psychotherapy to address guilt, shame, and MI stemming from traumatic events. The primary goals of TrIGR are to help patients accurately appraise their trauma and to re-engage with their values in order to lead a more meaningful life. This paper presents the rationale, design, and methodology of a two-site randomized controlled trial (RCT) examining the efficacy of TrIGR compared to Supportive Care Therapy (SCT) in a sample of U.S. veterans (N = 145) who endorse guilt related to a traumatic event that occurred during military deployment. This study is the first RCT powered to investigate TrIGR's efficacy on reducing posttraumatic guilt, as measured by the Trauma Related Guilt Inventory (TRGI), in comparison to an active control condition. In addition, the study will examine a range of secondary and exploratory outcomes including shame, quality of life, suicidal ideation, substance use, and PTSD and depression symptoms. Findings from this efficacy study will be essential in informing future efficacy and effectiveness trials.
Alcohol misuse and separation from military service: A dyadic perspective
2020, Addictive Behaviors
Alcohol misuse is a prevalent problem among military service members and their spouses. Service member alcohol misuse may contribute to poor job performance, legal infractions, and failure to meet physical standards. Spousal alcohol misuse may indicate problems with military life. However, limited information is available about how alcohol misuse in military families affects occupational outcomes, specifically military attrition.
The current study examined 7,965 opposite sex married couples from the Millennium Cohort Family Study with one military and one civilian/veteran partner. Both partners reported on three measures of alcohol misuse (binge drinking, alcohol problems, and heavy weekly drinking). The associations between each partner’s measures of alcohol misuse and subsequent military separation were evaluated using logistic regression. Sex, concordance of alcohol misuse, mental health, and service branch were explored as moderators.
In fully adjusted models, service member alcohol problems were directly related to military separation. Additionally, service member heavy weekly drinking was strongly associated with military separation among female service members but not male service members. Service member and spouse binge drinking interacted such that when only one partner reported binge drinking military separation was less likely, but both partners’ binge drinking conveyed a marginally increased risk of military separation.
Prevalence of alcohol misuse was high among military families. Service member alcohol misuse was more strongly related to military separation than spouse alcohol misuse. Additionally, heavy weekly drinking among female service members may be an indicator of a significant issue that merits interventions aimed at retaining these service members.
Can the migration process influence the clinical expression of heroin use disorder in migrants to Italy?
2021, CNS Spectrums

View all citing articles on Scopus

View full text

Substance abuse and post-traumatic stress disorder comorbidity

Abstract

J. Subst Abuse Treat.

Behav. Ther.

J. Subst. Abuse Treat.

Addict. Behav.

J. Subst. Abuse Treat.

J. Subst. Abuse Treat.

J. Subst. Abuse Treat.

Drug Alcohol Depend.

A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1

Behav. Ther.

Comorbid mental disorders in patients with AMA discharges from alcoholism treatment

Hosp. Commun. Psychiatry

Chronic combat-related concurrent substance abuse: Implications for treatment of this frequent ‘dual diagnosis.’

J. Traumatic Stress

Traumatic events and post-traumatic stress disorder in an urban population of young adults

Arch. Gen. Psychiatry

Psychopathology in male-substance abusers: Relationship to drug of choice and early trauma

Alcoholism and post-traumatic stress disorder among combat Vietnam veterans

Alcohol. Treat. Q.

Correspondence between MMPI PTSD measures and clinical diagnosis

J. Personality Assess.

Alcohol and tension reduction. An update on research and theory

Skill training with alcoholics

J. Consult. Clin. Psychol.

Psychobiologic mechanisms of posttraumatic stress disorder

Arch. Gen. Psychiatry

The effects of alcohol on conflict behavior in the albino rat

J. Stud. Alcohol

Post-traumatic stress disorder among substance users from the general population

Am. J. Psychiatry

Determinants of post-treatment functioning of alcoholic patients: A conceptual framework

J. Consult. Clin. Psychol.

Acute effects of drug abuse in schizophrenic patients: Clinical observations and patients' self-reports

Schizophrenia Bull.

Drug abuse in schizophrenic patients: Clinical correlates and reasons for use

Am. J. Psychiatry

Post-traumatic stress disorder in World War II and Korean combat veterans with alcohol dependency

Assertions regarding effectiveness of treatment for alcoholism: Fact or fantasy

Am. Psychol.

Treatment of post-traumatic stress disorder: Evaluating outcome with a behavioral code

Behav. Modification

Patterns of appraisal and coping across different stressor conditions among former prisoners of war with and without post-traumatic stress disorder

J. Consult Clin. Psychol.

Sexual abuse and its relationship to later sexual satisfaction, marital status, religion, and attiludes

J. Interpersonal Violence

Behavioral/cognilive conceptualizations of post-traumatic stress disorder

Behav. Ther.

Biological approaches to the diagnosis and treatment of post-traumatic stress disorder

J. Traumatic Stress

Psychiatric diagnosis

MMPI-2: Assessing personality and psychopathology

Long-term coping with combat stress

J. Traumatic Stress

Multiple diagnosis in post-traumatic slress disorder: The role of war stressors

J. Nerv. Ment. Dis.

Co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment

J. Stud. Alcohol

Post-traumatic stress disorder in the general population: Findings of the epidemiological catchment area survey

N. Engl. J. Med.

Mississippi Scale for Combat Related PTSD: Three studies in reliability and validity

J. Consult. Clin. Psychol.

Imaginai flooding in the treatment of a post-traumatic stress disorder

J. Consult. Clin. Psychol.

Empirical development of an MMPI subscale for the assessment of combat-related post-traumatic stress disorder

J. Consult. Clin. Psychol.

Comorbidity in post-traumatic stress disorder: An analysis of community and clinical studies

J. Appl. Soc. Psychol.

Post-traumatic stress disorder: Evidence for diagnostic validity and methods of psychological assessment

J. Clin. Psychol.

The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence

Am. J. Psychiatry

Self-regulation and self-medication factors in alcoholism and addictions: Similarities and differences