Attenuated psychotic symptoms, substance use and self-reported PTSD in adolescence

Background: To test whether an integrated prolonged exposure (PE) approach could address posttraumatic stress disorder (PTSD) symptoms effectively in individuals with co-occurring substance use disorders (SUD), we compared concurrent treatment of PTSD and SUD using PE (COPE) to relapse prevention therapy (RPT) for SUD and an active monitoring control group (AMCG). Methods: We conducted a randomized 12-week trial with participants (n = 110; 64% males; 59% African Americans) who met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria for full or subthreshold PTSD and SUD. Participants were randomly assigned to COPE (n = 39), RPT (n = 43), or AMCG (n = 28). Results: At the end-of-treatment, COPE and RPT demonstrated greater reduction in PTSD symptom severity relative to AMCG (COPE-AMCG = -34.06, p < 0.001; RPT-AMCG = -22.58, p = 0.002). Although the difference between COPE and RPT was not significant in the complete sample, the subset of participants with full (vs. subthreshold) PTSD demonstrated significantly greater reduction of PTSD severity in COPE relative to RPT. Both treatments were superior to AMCG in reducing the days of primary substance use (COPE-AMCG = -0.97, p = 0.01; RPT-AMCG = -2.07, p < 0.001). Relative to COPE, RPT showed significantly more improvement in SUD outcome at end-of-treatment (RPT-COPE = -1.10, p = 0.047). At 3-month follow-up, COPE and RPT maintained their treatment gains and were not significantly different in PTSD severity or days of primary substance use. Conclusion: COPE and RPT reduced PTSD and SUD severity in participants with PTSD + SUD. Findings suggest that among those with full PTSD, COPE improves PTSD symptoms more than a SUD-only treatment. The use of PE for PTSD was associated with significant decreases in PTSD symptoms without worsening of substance use.

The authors aim to delineate cognitive dysfunction associated with posttraumatic stress disorder (PTSD) by evaluating a well-defined cohort of former World War II prisoners of war (POWs) with documented trauma and minimal comorbidities. The authors studied a cross-sectional assessment of neuropsychological performance in former POWs with PTSD, PTSD with other psychiatric comorbidities, and those with no PTSD or psychiatric diagnoses. Participants who developed PTSD had average IQ, while those who did not develop PTSD after similar traumatic experiences had higher IQs than average (approximately 116). Those with PTSD performed significantly less well in tests of selective frontal lobe functions and psychomotor speed. In addition, PTSD patients with co-occurring psychiatric conditions experienced impairment in recognition memory for faces. Higher IQ appears to protect individuals who undergo a traumatic experience from developing long-term PTSD, while cognitive dysfunctions appear to develop with or subsequent to PTSD. These distinctions were supported by the negative and positive correlations of these cognitive dysfunctions with quantitative markers of trauma, respectively. There is a suggestion that some cognitive decrements occur in PTSD patients only when they have comorbid psychiatric diagnoses.

Background: Adolescent patients with a substance use disorder (SUD) often fulfil the criteria for a co-occurring post-traumatic stress disorder (PTSD). However, it is not clear if these dual-diagnosed adolescents present with unique levels of substance use and how their substance use relates to PTSD symptom clusters. Objective: To investigate substance use in adolescents with co-occurring PTSD and SUD. Additionally, we explored how the use of specific substances is related to specific PTSD symptom clusters. Method: We recruited n = 121 German adolescent SUD patients, in three groups: no history of traumatic events (TEs) (n = 35), TEs but not PTSD (n = 48), probable PTSD (n = 38). All groups were administered a trauma questionnaire and were asked to report their past-month substance use. Results: Adolescents with probable PTSD and SUD report a higher frequency of MDMA use than adolescents with no PTSD and no TE (PTSD vs. noTE: U = 510.5, p = .016; PTSD vs. TE: U = 710.0, p = .010). The use of MDMA was more frequent in adolescents with avoidance symptoms (X2 (1) = 6.0, p = .014). Participants report using substances at a younger age (PTSD vs. noTE: U = 372.0, p = .001; PTSD vs. TE: U = 653.5, p = .022) and PTSD symptom onset was on average 2.2 years earlier than first MDMA use (t (26) = −2.89, p = .008). Conclusions: Adolescent SUD patients with probable PTSD are more likely to use MDMA than SUD patients without PTSD. The use of MDMA was associated with reported avoidance symptoms. The first age of MDMA use is initiated after PTSD onset. It is unclear whether the association of MDMA use with avoidance symptoms is due to efforts to reduce these symptoms or a result of regular MDMA use.

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) often co-occur. Methods that can map symptom occurrences over time may shed light on the potential etiological and maintaining factors of such complex symptom presentations. The Longitudinal Follow-Up Evaluation (LIFE) is an assessment method that has been used to characterize the weekly course of psychiatric disorder. This pilot study examined the interrater reliability and concurrent validity of LIFE to assess PTSD and substance dependence symptom course over a period of 26 weeks among SUD outpatients (N = 35). Participants with trauma histories completed interviews, including the LIFE for the prior 6 months, and questionnaires. All interviews were scored by a second rater. Results indicated good interrater reliability for the weekly psychiatric status ratings (PSRs). Associations between PTSD and SUD PSRs with alternative measures of PTSD, substance use and abuse, and functional status supported the validity of the PSRs. These data suggest that the LIFE is a reliable and valid method to measure weekly symptoms of PTSD. This method may prove helpful in mapping the course of PTSD—SUD and, as such, allowing more rigorous tests of process-related models of PTSD and SUD such as self-medication.

This study examined the prevalence of lifetime traumatic events and current symptoms of posttraumatic stress disorder (PTSD) among treatment-seeking cocaine-dependent outpatients and compared patients with and without PTSD on current substance use, psychopathology, and sociodemographic characteristics. The subjects were 122 adult cocaine-dependent outpatients participating in a treatment outcome study of psychosocial therapy. In addition to standard self-report and interview measures of psychopathology and substance use, the subjects completed the Trauma History Questionnaire and the PTSD Checklist before entering treatment. These patients experienced a large number of lifetime traumatic events (mean = 5.7); men experienced more general disasters and crime-related traumas than women, and women experienced more physical and sexual abuse than men. According to self-report measures, 20.5% of the subjects currently met the DSM-III-R criteria for PTSD; the rate of PTSD was 30.2% among women and 15.2% among men. Patients with PTSD had significantly higher rates of co-occurring axis I and axis II disorders, interpersonal problems, medical problems, resistance to treatment, and psychopathology symptoms than patients without PTSD. Psychopathology symptoms represented the most consistent difference between the two groups and provided the best prediction of PTSD status in a logistic regression. However, the groups did not differ significantly in current substance use or sociodemographic characteristics. These findings underscore the value of screening substance abusers for PTSD, because it can identify a small but substantial number who might require additional treatment. Further studies of the relationship between PTSD and substance abuse appear warranted.

A significant number of adolescents in the U.S. experience traumatic events, putting them at risk for developing Posttraumatic Stress Disorder (PTSD). Despite this risk, PTSD is not a commonly assigned diagnosis in psychiatric settings. The current study examined rates of psychiatrist-reported PTSD (PR-PTSD) diagnoses compared to probable PTSD diagnoses based on adolescent self-reported PTSD (SR-PTSD) symptoms on a psychiatric inpatient unit (n = 151, age 13–17). Self-report measures included questions on exposure to trauma and The Child PTSD Symptom Scale for DSM-5 (CPSS-5). Approximately 60% of participants met criteria for a “probable PTSD diagnosis” on the CPSS-5; however, only 10 out of 151 (6.6%) and 58 out of 151 (38.4%) were given PR-PTSD at admission and at discharge, respectively. Chi-square analyses indicated adolescents with SR-PTSD were more likely to have previous psychiatric admissions, χ2(1, N = 149) = 3.87, p = .049. There was also a significant association between SR-PTSD and suicide risk, χ2(3, N = 148) = 9.93, p = .019. Both the null and low suicide risk groups contributed the most to predicting SR-PTSD based on the standardized residuals being ±1.96. Additionally, SR-PTSD and insurance status were significantly associated, χ2(1, N = 147) = 4.48, p = .034. All of the cells equally contributed to the significance. When comparing diagnosis given at admission to SR-PTSD, agreement was poor (κ=.070, p = .043), and there was no agreement between diagnosis given at discharge and SR-PTSD (κ=.116, p = .074). Findings from the study highlight a discrepancy in SR-PTSD and PR-PTSD in adolescent psychiatric settings.

ObjectivesAdolescents with substance use disorders (SUD) frequently report traumatic events (TEs) and symptoms of post-traumatic stress disorder (PTSD). This study aimed to assess whether lifetime prevalence rates of TEs and PTSD are related to SUD severity in adolescent psychiatric patients.MethodsWe analyzed N = 114 self-reports of treatment-seeking German adolescents aged 12 to 18 years, who visited a specialized SUD outpatient unit. Standardized questionnaires were applied to assess SUD severity, the number of TEs and DSM-IV PTSD criteria.ResultsPatients fulfilling PTSD criteria (28% of the total sample) had a higher Drug Use Disorders Identification Test (DUDIT) score compared to non-PTSD patients with TEs (p <.001), and compared to adolescents without TEs or PTSD (p = .003). Additionally, SUD severity was positively associated with the number of TEs and the number of intrusion, hyperarousal, and avoidance symptoms (all r = .33 to.48, all p <.01).DiscussionAdolescent patients with SUD reported 3-times higher rates of TEs, and a 5-time higher prevalence of PTSD following TEs, than the general adolescent population. Adolescent SUD patients with PTSD reported more severe substance use problems than patients without PTSD—regardless of previous TEs. Longitudinal studies are needed in order to investigate the temporal relationship between TEs, PTSD and SUD.

Objective: The frequent co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain has received much attention in the literature. However, the extant literature is limited in that these investigations generally exclude patients with co-occurring substance use disorders (SUD). Thus, the present study investigated symptoms of PTSD and SUD in veterans with high and low pain symptoms. Method: Veterans (N = 136) seeking treatment for comorbid symptoms of PTSD and SUD were recruited as part of a larger study. All participants completed a baseline assessment, which included a series of diagnostic interviews and self-report questionnaires measuring symptoms of pain, PTSD and SUD. Results: Higher levels of self-reported pain were found to be associated with both self-reported and clinician-rated PTSD symptoms above and beyond the influence of the demographic variables. However, no reliable relations were demonstrated between substance use and pain. Conclusions: Although preliminary, the findings highlight the common occurrence of chronic pain among veterans with comorbid PTSD/SUD, and the potential impact of pain on clinical presentation. The findings may help inform special considerations for assessment and treatment practices for this high-risk population.

Introduction: The aim of this study was to investigate the prevalence of traumatic experiences and symptoms of posttraumatic stress disorder (PTSD) in treatment-seeking individuals with ongoing substance use disorder (SUD) compared to individuals who have recovered from SUD. Methods: Patients with SUD recruited from the STAYER study (N = 114) underwent an examination of alcohol and drug use, childhood trauma, negative life events and PTSD symptomatology. In this study, only participants with 12-month concurrent polysubstance use was included. Using historical data from the STAYER study, alcohol and drug trajectories were dichotomised as (1) current SUD (current SUD) or (2) recovered from substance use disorder (recovered SUD). Crosstabs and chi-tests were used to measure differences between groups. Results: Childhood maltreatment, traumatic experiences later in life and symptoms of concurrent PTSD were highly prevalent in the study population. We found no significant difference between the current and recovered SUD groups. Recovered women reported a lower prevalence of physical neglect (p = 0.031), but a higher prevalence of multiple lifetime traumas (p = 0.019) compared to women with current SUD. Both women with current SUD and recovered women reported a significantly higher prevalence of sexual aggression than men (p < 0.001 and p < 0.001, respectively). In addition, men who have recovered from SUD reported a lower prevalence of PTSD symptoms over cut-off 38 (p = 0.017), of re-experiencing (p = 0.036) and of avoidance (p = 0.015), compared to recovered women. Conclusion: Reported trauma did not differ between persons with current SUD and those who had recovered from SUD. Gender differences discovered in this study indicate the importance of developing individualised and gender-specific treatment models for comorbid PTSD/SUD.

ObjectivesBoth substance use, on the one hand, and the first signs of psychosis, on the other, commonly begin in adolescence. Adolescents with substance use disorder (SUD) frequently show recreational use of cannabis and 3,4-methylenedioxymethamphetamine (MDMA). When attenuated psychotic symptoms (APS) occur during the course of SUD, they are commonly attributed to the cannabis use, neglecting the role of other substances abused, such as MDMA in the risk of psychosis.MethodsWe analyzed retrospective self-reports on APS (Prodromal Questionnaire, PQ-16) and amount of cannabis and MDMA use in n = 46 adolescent psychiatry outpatients with SUD. N = 17 (35%) individuals reported MDMA consume additional to cannabis. Furthermore, we examined the associations of APS with cannabis and MDMA use in stepwise hierarchical regressions while controlling for trauma history, birth complications and gender.ResultsAPS were not related to cannabis (B = 0.04, p = 0.842), but to MDMA use (B = 4.88, p = 0.001) and trauma history (B = 0.72, p = 0.001). Gender (B = −0.22, p = 0.767) and birth complications (B = −0.68, p = 0.178) were not associated with APS.DiscussionOur results indicate that MDMA use additional to cannabis use is associated with APS among adolescent SUD patients. Contrary to our expectations, we did not see an association of cannabis use and APS. We speculate that cannabis increases the risk for psychosis after a longer period of use and in combination with other risk factors, such as trauma history. Clinicians should screen for APS among SUD patients using MDMA and cannabis in order to adapt treatment plans of SUDs. Future research should validate these findings in longitudinal studies including polysubstance use and trauma history.

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) are highly co-occurring and evidence for the optimal ways of treating PTSD in SUD patients is mixed. Our aim was to compare three different PTSD treatments, each added simultaneously to SUD treatment, with SUD treatment alone in patients with co-occurring SUD-PTSD. These PTSD treatments were: Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR) and Imagery Rescripting (ImRs). A single-blind 4-arm randomized controlled trial with follow-up at 3months. Two addiction treatment centers in the Netherlands, providing intra- and extramural care. 209 patients with SUD and co-morbid PTSD were included [mean age 37.5 (standard deviation, SD = 11.99), female sex = 46.4%, mean Clinically Administered PTSD Scale (CAPS) score = 37.35 (SD = 9.28)]. Participants were randomized to either simultaneous SUD + PE (n = 53), SUD + EMDR (n = 50), SUD + ImRs (n = 55) or to SUD treatment only (n = 51), with the active PTSD treatments consisting of 12 sessions each within 3months. Standard protocols were used. The primary outcome was clinician-administered PTSD symptom severity as measured by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (CAPS-5) at 3month follow-up. Secondary outcomes included loss of PTSD diagnosis, full remission of PSTD and SUD-severity, also recorded at 3months. Compared with SUD only, the mean differences in CAPS-5 score were B = -5.41 [95% confidence interval (CI) = 10.88, 0.05, P = 0.052] for SUD + PE, B = -7.97 (95% CI = -13.57, -2.37, P = 0.006) for SUD + EMDR and B = -10.03 (95% CI = -15.29, -4.77, P < 0.001) for SUD + ImRs. When adjusted for baseline covariates, mean differences were B = -5.81 (95% CI = -11.48, -0.15, P = 0.044) for SUD + PE, B = -8.85 (95% CI = -14.60, -3.10, P = 0.003) for SUD + EMDR and B = -10.75 (95% CI = -15.94, -5.56, P = <0.001) for SUD + ImRs. No between-group differences in SUD outcomes were found. Among people with co-occurring substance use disorder (SUD) and post-traumatic stress disorder (PTSD), trauma-focused PTSD treatment as add-on to SUD treatment appears to be effective in decreasing PTSD severity compared with manualized SUD only treatment and does not appear to increase SUD severity.

We review 15 studies that examined rates of post-traumatic stress disorder (PTSD) in substance use disorder (SUD) patients to determine whether the typical female-greaterthan-male gender difference in PTSD rates is attenuated in SUD samples. Since the majority of studies reviewed did not find a gender difference in PTSD rates, we critically examined methodological factors that might account for this attenuation, but none appeared to completely account for the variability in detection of gender differences across studies. Several factors may contribute to making rates of PTSD among SUD males equivalent to the high rates observed in SUD females: 1) the risky lifestyle associated with men's substance abuse may increase their exposure to traumatic events, 2) a history of more severe trauma characteristics may be apparent among men with SUDs, or 3) attenuated gender differences in rates of other comorbidities that increase PTSD risk (e.g., depression) may exist. Clinical implications are discussed. According to epidemiological studies, post-traumatic stress disorder (PTSD) is a highly comorbid condition among those with substance use disorders (SUDs; see review by Stewart, 1996). In the National Comorbidity Survey, a large-scale epidemiologic survey conducted in the U.S., Kessler and colleagues (1997) found that those with alcohol dependence were at 3-4 times increased risk of lifetime PTSD as compared to those without alcohol dependence. Moreover, the presence of comorbid PTSD among individuals being treated for SUDs is related to poorer treatment adherence (Hien, Nunes, Rudnick Levin, & Fraser, 2000) and outcomes, including higher relapse rates (e.g., Ouimette, Brown, & Najavits, 1998; Ouimette, Finney, & Moos, 1999). It has been suggested that if patients with comorbid SUD-PTSD were to receive trauma-specific treatment, they might avoid overutilizing or misusing expensive inpatient SUD treatments, thereby reducing the cost of clinical care (e.g., Brown, Recupero, & Stout, 1995). The delineation of gender variations in the presentation of this comorbidity may identify factors that will improve treatment outcomes (Sonne et al., 2003). A fairly consistent finding across epidemiologic studies on PTSD rates in the general adult population is that women are about twice as likely to have PTSD as men (e.g., Breslau, Chilcoat, Kessler, Peterson, & Lucia, 1999; Breslau, Davis, Andreski, & Peterson, 1991; Breslau, Davis, Andreski, Peterson, & Schultz, 1997; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Moreover, women experience qualitatively different traumatic life experiences than do men. These findings have led to an interest in understanding gender differences in PTSD and their implications for etiology and treatment of the disorder (e.g., Kimerling, Ouimette, & Weitlauf, in press). Early research on comorbid PTSD-SUDs focused almost exclusively on male veterans whose pathology arose in the context of combat trauma; more recently, a focus has emerged on women with comorbid PTSD-SUDs (Najavits, Weiss, & Shaw, 1997). The major purpose of this article is to examine gender as an important individual difference variable with respect to trauma and PTSD among patients with SUDs. This brief review focuses on rates of trauma and PTSD among clinical samples of male and female SUD patients. Summaries of the methods and findings of the studies reviewed in this article are provided in Tables 1 and 2, for trauma exposure rates and PTSD rates, respectively. Gender Differences in Adult Samples Brown et al. (1995) studied the prevalence of trauma histories and comorbid PTSD among 84 adults (48 male; 36 female) seeking treatment at a private hospital inpatient substance-abuse treatment program. Participants completed self-report measures of lifetime trauma exposure and PTSD symptoms. Women were more likely than men to have been physically abused/assaulted (31% vs. …

To determine the relations between obstructive sleep apnea (OSA) diagnosis, the likelihood of being diagnosed with a psychological condition, among obese veterans, after accounting for severity of obesity and the correlated nature of patients within facility. We hypothesized that (1) individuals with a diagnosis of OSA would be more likely to receive a diagnosis of a (a) mood disorder and (b) anxiety disorder, but not (c) substance use disorder. Cross-sectional retrospective database review of outpatient medical records between October 2009 and September 2010, conducted across all 140 Veterans Health Administration (VHA) facilities. The entire VA Health Care System. Population-based sample of veterans with obesity (N = 2,485,658). Physician- or psychologist-determined diagnosis of psychological conditions including mood, anxiety, and substance use disorders. Using generalized linear mixed modeling, after accounting for the correlated nature of patients within facility and the severity of obesity, individuals with a diagnosis of sleep apnea had increased odds of receiving a mood disorder diagnosis (OR = 1.85; CI = 1.71-1.72; p < 0.001), anxiety disorder diagnosis (OR = 1.82; CI = 1.77-1.84; p < 0.001), but not a diagnosis of substance use disorder. Among obese veterans within VA, OSA is associated with increased risk for having a mood and anxiety disorder, but not substance use disorder, with the strongest associations observed for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). In addition, this relation remained after accounting for severity of BMI.

FC01-04 - Exposure to traumatic events and posttraumatic stress disorder symptoms in substance use disorder inpatients

Substance use and posttraumatic stress disorders: Symptom interplay and effects on outcome