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Brian L. Meyer, Ph.D.Brian L. Meyer, Ph.D.Interim Associate Chief, Interim Associate Chief,
Mental Health Clinical ServicesMental Health Clinical ServicesMcGuire VA Medical CenterMcGuire VA Medical Center
Richmond, VARichmond, VAOctober 28, 2014October 28, 2014
DisclaimerDisclaimer
The views expressed in this presentation are solely those of the presenter and do not represent those of the Veterans Health Administration, the Department of Defense, or the United States government.
Co-Occurrence of Co-Occurrence of PTSD and Substance AbusePTSD and Substance Abuse
Co-occurring disorders are the rule rather than the exception.
(SAMHSA, 2002)
PTSD Co-MorbiditiesPTSD Co-Morbidities
Kessler et al., 1995
Co-Occurrence of Co-Occurrence of PTSD and SUDsPTSD and SUDs
PTSD and substance abuse co-occur at a high rate20-40% of people with PTSD also have SUDs
(SAMHSA, 2007)40-60% of people with SUDs have PTSD
Substance use disorders are 3 times more prevalent in people with PTSD than those without PTSD
The presence of either disorder alone increases the risk for the development of the other
The combination results in poorer treatment outcomes
Co-Occurring PTSD and SUDs Co-Occurring PTSD and SUDs Make Each Other WorseMake Each Other Worse
Substance abuse exacerbates PTSD symptoms, including sleep disturbance, nightmares, rage, depression, avoidance, numbing of feelings, social isolation, irritability, hypervigilance, paranoia, and suicidal ideation
People who drink or use drugs are at risk for being retraumatized through accidents, injuries, and sexual trauma
PTSD and Substance AbusePTSD and Substance AbusePTSD/SUD patients have significantly
greater impairmentsOther Axis I disordersIncreased psychiatric symptomsIncreased inpatient admissionsInterpersonal problemsMedical problemsDecreased motivation for treatmentDecreased compliance with aftercareMaltreatment of childrenCustody battlesHomelessnessHIV risk
Veterans in PrisonVeterans in PrisonBy 1985, more that 1/5 prison inmates were
Veterans (Daily Beast, 7/28/13)
By 1988, more than half of all Vietnam Veterans with PTSD had been arrested More than 1/3 had been arrested multiple times
(NCPTSD) 1/11 prison inmates are Veterans (DOJ, 2004)
This is about 223,000 people56,000 Veterans are released from state and
federal prisons annually, and another 90,000 are released from city and county jails (Noonan, 2010)
Veterans and CriminalityVeterans and CriminalityWe do not know how many Veterans of the Iraq and
Afghanistan conflicts are in prison because the last Dept. of Justice survey was completed in 2004The best estimate is 9% (Elbogen et al., 2012)
This percentage is likely to rise, since the numbers and percentage of Veterans in prison rises after wars
The primary reason Veterans are arrested is substance abuse (Beckerman, et al. 2009; Erickson, et al. 2008)
The other major reason is PTSDWhen irritability and anger are high, 23% of OEF/OIF
Veterans with PTSD have been arrested (Elbogen et al., 2012)
Trauma and PTSDTrauma and PTSDMore men (61%) than women (51%)
experience a trauma at some point in their lives, but women experience PTSD at twice the rate of men (10% vs. 5%) (Kessler et al., 1995; Tolin and Foa, 2006)
Depending on the study, the type of trauma, and the group studied, 3%-58% get PTSD
Therefore, not all trauma leads to PTSD
Life-Threatening EventsLife-Threatening Events
IMPERSONAL
PERSONAL
TRAUMATIC
Who Gets PTSD?Who Gets PTSD?It depends on:
GeneticsSeverityDurationProximity
PTSD is mitigated or worsened by:Childhood experiencePersonality characteristicsFamily historySocial support
(Overactive)
(Smaller volume)
(Underactive)
Amygdala – Emotional reactions, fight or flight alarm system
Hippocampus – Relay station for sorting memories
Prefrontal cortex – logic, reasoning, planning, impulse control, organizing
Changes to PTSD Changes to PTSD Diagnosis in DSM 5*Diagnosis in DSM 5*
Trauma and Stressor-Related Disorders are placed in their own category
Loss of loved one must be traumatic or accidental
Elimination of B criterion of reaction of horror, terror, or helplessnessMilitary and first responders do
their job* Indicates material in packet
Changes to PTSD Changes to PTSD Diagnosis in DSM 5Diagnosis in DSM 5
Addition of new criteria involving negative cognitions (negative beliefs about the world, blame of self or others for the trauma) and mood (depression, anger, guilt)
Addition of a new arousal criterion: self-destructive or reckless behavior
These changes result in approximately the same number of people who will meet criteria for a diagnosis of PTSD
Post-Traumatic Post-Traumatic Stress Disorder in DSM 5Stress Disorder in DSM 5
PTSD is characterized by:
Exposure to a severe life-threatening event
Repetitive re-experiencing of the event Avoidance of stimuli associated with
trauma Negative moods and cognitions Increased arousal
PTSD: Exposure to a Life-PTSD: Exposure to a Life-Threatening EventThreatening Event
A. Exposure to a traumatic event
Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence
PTSD: Intrusion SymptomsPTSD: Intrusion SymptomsB. Intrusion symptoms: Recurrent, involuntary and intrusive
recollectionsTraumatic nightmaresDissociative reactions (e.g., flashbacks)Intense or prolonged distress after
exposure to traumatic remindersMarked physiological reactivity to
trauma-related stimuli
PTSD: Avoidance of Stimuli PTSD: Avoidance of Stimuli Associated with Traumatic EventAssociated with Traumatic Event
C. Persistent effortful avoidance of distressing trauma-related stimuli after the event:
Trauma-related thoughts and feelings
Trauma-related external reminders
PTSD: Negative PTSD: Negative Cognitions and MoodCognitions and Mood
D. Negative alterations in cognitions and mood that began or worsened after the traumatic event:
Inability to recall key features of the traumatic event
Persistent negative beliefs and expectations about self or world
Persistent distorted blame of self or others for causing the event or the resulting consequences
PTSD: Negative PTSD: Negative Cognitions and MoodCognitions and Mood
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame)
Markedly diminished interest in significant activities
Feeling alienated from othersConstricted affect: persistent
inability to experience positive emotions
PTSD: Increased Arousal PTSD: Increased Arousal and Reactivityand Reactivity
E. Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event:
Irritable or aggressive behaviorSelf-destructive or reckless behaviorHypervigilanceExaggerated startle responseProblems in concentrationSleep disturbance
PTSD: A New SubtypePTSD: A New Subtype
Dissociative Subtype of PTSD:Meets criteria for a diagnosis of PTSDExperiences high levels of
depersonalization or derealizationDissociative symptoms are not related to
substance abuse or other medical condition
Implications of Changes to Implications of Changes to PTSD Diagnosis in DSM 5PTSD Diagnosis in DSM 5
Angry, depressive, and anxious affects now applyThis is a rejoinder to the fear-based model of the
past, recognizing greater complexityThe existence of a dissociative subtype, combined
with the new affective criteria and the new arousal criterion of self-destructive behavior, moves the description closer to that of Complex Trauma
Some of the research on PTSD may no longer apply
Implications of Changes to Implications of Changes to PTSD Diagnosis in DSM 5PTSD Diagnosis in DSM 5
Assessment instruments must changeDifferent treatments may be needed for different
phenotypes of PTSD (anger, depression/guilt, anxiety, dissociation)This may decrease the use of certain
treatments, particularly Prolonged Exposure, which is fear-based
Inside the Skin of PTSDInside the Skin of PTSDNerves on edgeJumpyCan’t sleepNightmaresIrritable all the timeExplosive outburstsWants to be left
aloneDepressedCan’t stand crowdsHeart races/sweats
Inside the Skin of PTSDInside the Skin of PTSDHates New Year’s Eve and
July 4th
SecretiveDistrusts othersSees world as dangerousConstantly watching for
dangerHates linesOverwhelmed by stimulationFeels responsible for trauma
Inside the Skin of PTSDInside the Skin of PTSD
Copes by:Cutting off relationshipsIsolatingTaking risksSelf-harming behaviorsUsing drugs and alcohol
Some Consequences of PTSDSome Consequences of PTSDDamaged relationshipsStrain on familiesDomestic violenceMultiple marriagesProblems in parentingChildren develop problems
More Consequences of PTSDMore Consequences of PTSDLost productivityPovertyHomelessnessLegal problemsReduced quality of
life
PTSD: A Case ExamplePTSD: A Case ExampleMr. V: Vietnam Veteran; many battles; career Marine/Army man; married twice; automobile accident; became agoraphobic; startles easily; doesn’t trust others; nightmares; wife said she’s leaving; dissociated and shot up the house; arrested and jailed
PTSD: A Case ExamplePTSD: A Case ExampleMr. E: Army; guarded Tomb of the Unknown Soldier; engaged; apartment broken into; tortured; fiancée raped; fear of sleeping at night; triggered by sports games; became hypersexual; seven children by four women; became dependent on PCP; drove while high, arrested, and jailed for nine months
PTSD: A Case ExamplePTSD: A Case ExampleMr. G: Gulf War Veteran; sent woman out on convoy who was killed; significant guilt; isolated; began drinking and using crack cocaine; arrested and jailed; treated and stopped using crack; got comfortable and started drinking again; dissociated and arrested for drunk driving; jailed for a year
Resources for PTSDResources for PTSDHandbook of PTSD by Matthew Friedman,
Terence Keane, and Patricia ResickOnce a Warrior, Always a Warrior: Navigating
the Transition from Combat to Home--Including Combat Stress, PTSD, and mTBI by Charles Hoge
When Someone You Love Suffers from Posttraumatic Stress: What to Expect and What You Can Do by Claudia Zayfert and Jason Deviva
Resources for PTSDResources for PTSDNational Center for PTSD:
www.ptsd.va.govInternational Society for Traumatic Stress
Studies: www.istss.orgInternational Society for the Study of
Trauma and Dissociation: www.isst-d.orgPTSD 101 courses:
www.ptsd.va.gov/professional/ptsd101/course-modules.asp
