# Presentation: 005192

## Trauma and PTSD: Issues in the Treatment of Drug-Dependent Women

- Denise Hien, Ph.D.
- Research Scholar, Columbia University School of Social Work, Social Intervention Group
- Executive Director, Women’s Health Project Treatment and Research Center, St. Luke’s-Roosevelt Hospital
- NIDA-sponsored Symposium: Drug Abuse Treatment Issues in Women, American Psychiatric Association Meeting, May 5, 2004

## Overview of Presentation

- To highlight the historical roots of treatment for traumatic stress and addictions in women
-  To address the relationship between traumatic stress and addiction in women
- To present empirically supported treatment approaches for traumatic stress and addictions, highlighting manualized approaches and research findings

## Historical Context for the Study of Trauma and Addiction

- Historical Context for the Study of Trauma and Addiction

- Women’s Movement and Grassroots Advocacy for Battered Women in 1970s.
- Crack/Cocaine epidemic; DSM-IIIR broadens criteria for PTSD; PTSD studies in Vets and Non Substance Abusers; Fullilove’s Snowball Sample, Miller’s work with criminal justice population in mid-late 1980s.
- Surgeon General Koop declares Violence a Public Health Epidemic in 1991.
- Judith Herman’s book *Trauma and Recovery* published in 1992.

## Historical Context for the Study of Trauma and Addiction (cont’d.)

- Historical Context for the Study of Trauma and Addiction (cont’d.)

- Epidemiology from cross-disciplinary research over the late ‘80s and ‘90s establishes high rates—surpassing normal population estimates—for childhood abuse, domestic violence, crime victimization, and PTSD—especially for women.
- Kendler and colleagues publish first co-twin study demonstrating causal link between childhood abuse and substance use disorders in 2000.
- National consciousness of PTSD and addiction links following September 11, 2001.

## DSM-IV Criteria for Posttraumatic Stress Disorder (PTSD)

- A. The person has been exposed to a *traumatic event*
- event involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
- The person’s response involved intense fear, helplessness, or horror
- B. The traumatic event is persistently *reexperienced*
- C. *Avoidanc*e of stimuli associated with the trauma and numbing of general responsiveness
- D. Persistent symptoms of increased *arousal*, including difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response (American Psychiatric Association, 1994)

## Neurobiological Changes in Response to Traumatic Stress

- Limbic System -- Hippocampus and Amygdala
- Neurotransmitters and Peptides
- Changes in Hormonal System (HPA axis)

**Notes:**
Phase of Illnesses of chronic recurrent disorders is critical. 

## Relationship between Neurobiological Changes and PTSD Symptom Clusters

- Re-experiencing
- Avoidance/Numbing
- Hyperarousal

- Smaller Hippocampal Volumes
- Opioid Peptide System and Stress-related Analgesia
- Emotion Processing in the Amygdala and the Arousal System (HPA Axis)

## Simple vs. Complex PTSD

*Simple PTSD* typically develops from one incident, usually experienced as an adult.
*Complex PTSD* is associated with repeated incidents (domestic violence or ongoing childhood abuse).
- Broader range of symptoms: self-harm, suicide, dissociation (“losing time”); problems with relationships, memory, sexuality, health, anger, shame, guilt, numbness, loss of faith and trust, feeling damaged.

## Features of “Complex PTSD” or “DESNOS”A complex of symptoms associated with early interpersonal trauma

- Features of “Complex PTSD” or “DESNOS”*A complex of symptoms associated with **early interpersonal trauma*

- Alterations in
- the regulation of affective impulses (e.g., difficulty with modulation of anger and being self destructive)
- attention and consciousness leading to amnesias, dissociative episodes, and depersonalization
- self-perception (e.g., chronic sense of guilt and shame)
- interpersonal relationships (e.g., not being able to trust, not being able to feel intimate with people)
- somatization
- systems of meaning

## Pathways Between Trauma-related Disorders and Substance Use

- PTSD

- SUD

- TRAUMA

## Clinical Challenges in the Treatment of Traumatic Stress and Addiction  

- Clinical Challenges in the Treatment of Traumatic Stress and Addiction

- Abstinence may not resolve comorbid trauma-related disorders
-  for many patients the PTSD worsens
- Women with PTSD abuse the *most severe substances *and are vulnerable to *relapse for both conditions, as well as repeated trauma*
- Confrontational approaches typical in addictions settings frequently exacerbate mood and anxiety disorders

- 12-Step Models often do not acknowledge the need for pharmacologic interventions
- Treatment programs often do not offer integrated treatments for Substance Use and PTSD
- Treatments for only one disorder, such as Exposure-Based Approaches, are often marked by complications
- treatments developed for PTSD alone may not be advisable to treat women with addictions

**Notes:**
Phase of Illnesses of chronic recurrent disorders is critical. 

## The first woman, created by Hephaestus (God of Fire) endowed by the gods with all the graces and treacherously presented with a box in which were confined all the evils that could trouble mankind. 

As the gods had anticipated, Pandora opened the box, allowing the evils to escape. 

- The first woman, created by Hephaestus (God of Fire) endowed by the gods with all the graces and treacherously presented with a box in which were confined all the evils that could trouble mankind.
- As the gods had anticipated, Pandora opened the box, allowing the evils to escape.

**Pandora**

## Empirically Supported  Behavioral Treatments for PTSD and SUD

- Sequential, Phase-Based Models:
- 	Brady et al.
- 	Triffleman et al.
- Integrated Model:
- 	Najavits et al.
- 	Hien et al.

## Slide 14

## Seeking Safety---Lisa Najavits, Ph.D.Harvard Medical School, www.seekingsafety.org

- Developed as a group treatment for PTSD/SUD women
- Based on CBT models of SUDs, PTSD treatment, women’s treatment, and educational research
- Educates patients about PTSD and SUDs and their interaction
- Goals include abstinence and decreased PTSD symptoms
- Focuses on enhancing coping skills, safety, and self-care
- Active, structured treatment - therapist  teaches, supports and encourages
- Case management

## Hien et al. Phase IB Study Designfunded by Violence Against Women and Families Consortium, (NIJ-NIDA lead institutes)

- Hien et al. Phase IB Study Designfunded by Violence Against Women and Families Consortium, (NIJ-NIDA lead institutes)

- Randomized clinical trial
- 3 month cognitive behavioral individual psychotherapy treatments
- Seeking Safety--L. Najavits, Ph.D.
- Relapse Prevention Treatment--K. Carroll, Ph.D.
- Non-randomized treatment-as-usual comparison condition

## Outcomes

- Primary Outcomes
- PTSD Symptom Severity
- SUD Symptom Severity
- Secondary Outcomes
- Psychiatric Symptom Severity
- Coping
- Emotion Regulation
- Retention

## Demographic Characteristics by Treatment Type (Total N=107)

## Seeking Safety (SS) vs. Relapse Prevention (RPT) vs. TAU Outcomes: Posttraumatic Stress Symptom Severity by Treatment Group (N=107)

- Seeking Safety (SS) vs. Relapse Prevention (RPT) vs. TAU Outcomes: Posttraumatic Stress Symptom Severity by Treatment Group (_N_=107)

- **_P_<.01

- **_P_<.01

- All analyses adjusted for age and baseline PTSD severity. End-of-Tx _F_=4.71 (2,106),
- r2=.42; 3-month Post _F_=4.94 (2,106), r2=.28; 6-month Post _F_=5.51 (2,106), r2=.22. Findings reported in Hien, DA, Cohen, LR, Litt, LC, Miele, GM & Capstick, C. (Under Revision), Promising Empirically Supported Treatments for Women with Comorbid PTSD and SUD, *American Journal of Psychiatry*. Do not cite without permission of the authors.

- **_P_<.01

## Seeking Safety (SS) vs. Relapse Prevention (RPT) vs. TAU Outcomes: Substance Use Severity by Treatment Group (N=107)

- Seeking Safety (SS) vs. Relapse Prevention (RPT) vs. TAU Outcomes: Substance Use Severity by Treatment Group (_N_=107)

- ***_P_<.001

- *_*P_<.01

- All analyses adjusted for age and baseline substance use severity. End-of-Tx _F_=6.01 (2,106),
- r2=.42; 3-month Post _F_=4.82(2,106), r2=.36; 6-month Post _F_=2.87(2,106), r2=.35. Findings reported in
- Hien, DA, Cohen, LR, Litt, LC, Miele, GM & Capstick, C. (Under Revision), Promising Empirically Supported Treatments for Women
- with Comorbid PTSD and SUD, *American Journal of Psychiatry*. Do not cite without permission of the authors.

- _P_=.06

## Retention: Percentage of “Completers” by Treatment Group (SS vs. RPT) (N=68)

- _N_=28

- _N_=24

- _N_=20

- _N_=18

## Findings

- Both active treatments significantly impacted primary outcomes (PTSD and SUD) at post-treatment.
- Retention rates also did not statistically differ between the two treatments.
- Short term CBT treatments can have a significant impact on symptom outcomes for a population characterized by severe and complex trauma.
- PTSD treatment DOES NOT result in increased symptoms of either PTSD or SUD in early recovery.
- Standard RPT can also be an effective first step treatment for comorbid PTSD and SUD.

## Implications for Field

- Treatment research which examines longer-term interventions and outcomes is indicated.
- Improving retention remains a clinical challenge.
- Studies are needed which test effects of elements such as:
-  timing of sessions in the context of substance abuse treatment,
- optimal dose,
- combination psychopharmacology and behavioral interventions,
- addition of exposure therapy.

## Slide 24

## Women’s Health Project Treatment and Research Center

- Women’s Health Project Treatment and Research Center

**Part of the Addictions Institute of New York (formerly Smithers) in the Department of Psychiatry, St. Luke’s Roosevelt Hospital Center**
**Member of the Clinical Trials Network Long Island Node**
**Located in Morningside Heights, 114****th**** Street**
**Website: www.whpnyc.org**
**Pre- and Postdoctoral Psychology, Psychiatry and Social Work Training Internships**