Substance Abuse and Dependence

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Researchers using something called an odds ratio, which measures the odds of having one disorder if an individual has the other disorder, have measured the rates of comorbid Substance Abuse and PTSD. Studies have revealed the range of odd ratios for comorbid Alcohol Dependence or Abuse is 2.06 to 4.25. This means that if someone has PTSD, his or her odds of having an Alcohol Abuse or Dependence Disorder is anywhere from two to four times higher than if they did not have PTSD. Regarding Substance Abuse or Dependence, the range of odds ratios from various studies is 2.48 to 8.68. Again, this means that the odds of someone with PTSD also having a comorbid Substance Abuse or Dependence Disorder is anywhere from 2.5 times to 8.5 times higher than if he or she did not have PTSD.

Posttraumatic Stress Disorder patients with comorbid Substance Abuse or Dependence Disorders have been found to have higher levels of pathology in both disorders, more stressors, higher rates of health care utilization, less effective coping skills, and poorer responses to treatment than either disorder alone (Meichenbaum, 2003). Additionally, comorbid disorders of Panic Disorder, Major Depressive Disorder, Personality Disorders, Antisocial Behavior, and violence exist at higher rates. A quick summary of the DSM-IV-TR criteria for Substance Abuse are characterized by at least one of the following:

1. Recurrent substance use resulting in failure to fulfill major role obligations.

2. Recurrent substance use in situations in which it is physically hazardous.

3. Recurrent substance-related legal problems.

4. Continued substance use despite having persistent and recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

The criteria for Substance Dependence are represented by the presence of three or more of the following:

1. Tolerance as defined by either a need for increased amounts of the substance in order to achieve intoxication or the desired effect or markedly diminished effect of continued use of the same amount.

2. Withdrawal as manifested by either a characteristic withdrawal syndrome or the same substance is taken to relieve or avoid withdrawal symptoms.

3. The substance is taken in larger amounts or over a longer period than was intended.

4. There is a persistent desire or unsuccessful efforts to cut down or control use.

5. A great deal of time is spent in activities necessary to obtain the substance.

6. Important life activities are given up or reduced.

7. The use is continued despite knowledge of having persistent or recurrent physical or psychological problems likely caused or exacerbated by the substance use.

There have been three main hypotheses put forward to explain the comor-bid relationship between PTSD and Substance Abuse Disorders: (1) the self-medication hypothesis, (2), the high-risk hypothesis, (3) and the susceptibility hypothesis. We will cover the self-medication hypothesis in more detail in the following section. The high-risk hypothesis holds that individuals that use drugs live lives that are riskier and that bring them into higher frequency contact with traumatic stressors. The susceptibility hypothesis holds that individuals with Substance Abuse Disorders are at higher risk for developing PTSD once they have been exposed to a traumatic stressor because of the psychophysiological and psychological effects of substance abuse. This is a model of vulnerability to PTSD. Chilcoat and Menard (2003) remind us that there could also be a fourth, unrelated factor that accounts for the high comorbidity, something that both disorders and dually diagnosed individuals have in common. Stewart and Conrod (2003), for example, have proposed that this fourth factor could be that once the baseline symptoms of the two disorders are mutually established, the symptoms reinforce each other and develop into a vicious cycle. Ultimately, however, despite the plausibility of any one of these models, no one model has emerged as more empirically reliable to this date.

In returning to the self-medication hypothesis, research has shown that in the comorbid population, the development of PTSD typically precedes Substance Abuse or Dependence. Some research has shown that PTSD sufferers who have high levels of anxiety sensitivity (i.e., are very sensitive to low levels of anxiety) and who catastrophize about the consequences of their anxiety are more likely to cope with drugs that reduce arousal, such as central nervous system suppressants (Stewart & Conrod, 2003). This suggests that hyperarousal symptoms may be the link for the self-medication hypothesis. Alcohol and certain drugs that are particularly effective at inhibiting activity in anxiety-related brain circuitry have been found effective at reducing the startle response. Alcohol, for example, has been shown to reduce the startle response and has particular effects on the amygdala and the prefrontal cortex (for more on the biological underpinnings of PTSD, see Chapter 6). Although substances are sought to reduce symptoms, they may have the paradoxical effect of worsening other symptoms. For example, substances that interfere with hippocampus and prefrontal cortex functioning may interfere with extinction of trauma memories that would normally occur with long-term memory processing and consolidation of traumatic memories. Further, physiological withdrawal may worsen the symptoms that the individual was initially trying to escape, perhaps leading to increased use.

Treatment Issues

Ouimette, Moos, and Brown (2003, p. 93) state that a "fundamental concern voiced by providers who treat SUD-PTSD patients is when in the treatment course to address substance use and when to address PTSD." They cite that most clinical researchers suggest concurrent treatment. Ouimette, Moos, and Brown make the following four recommendations for an empirically based comorbid PTSD-Substance Abuse/Dependence practice:

1. Substance Abuse or Dependence patients should be routinely screened for PTSD.

2. Comorbid patients should be referred for concurrent trauma or PTSD treatment or for psychological treatment with the recommendation that trauma or PTSD issues be addressed.

3. Comorbid patients should be referred for concurrent participation in self-help groups and, when indicated, for family treatment.

4. Providers should offer comorbid patients continuing outpatient mental health care.

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Getting to Know Anxiety

Getting to Know Anxiety

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