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Alcoholism and Drug Abuse in patients with PTSD


The combination of PTSD and substance abuse is both common and problematic. In this chapter we review the following questions: 1) What is the relationship between PTSD, Alcoholism, and Drug Abuse? 2) Can the general “dual diagnosis” literature be of help? 3) Is the phenomenology of PTSD combined with alcoholism and/or drug abuse either unique or specific? 4) Does current pathophysiologic data allow conceptualization of a neurobiological model of PTSD, alcoholism, and drug abuse? 5) Drawing on these ideas, on the limited treatment literature, and the “dual diagnosis” literature, can we develop rational assessment and treatment approaches? Available literature suggests that diagnoses can be validly applied to these patients; that the illnesses must be treated simultaneously as co-primary illnesses; that extreme psychological symptoms reduce the efficacy of alcoholism or drug abuse treatment; and that effective control of these symptoms improves treatment outcome.

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  1. 1.

    Davidson RT, Kudler HS, Saunders WB, et al: Symptom and comorbidity patterns in World War II and Vietnam veterans with post traumatic stress disorder. Comprehensive Psychiatry 31:162–170, 1990.

    Google Scholar 

  2. 2.

    Escobar JI, Randolph ET, Puente G, et al: Post-traumatic stress disorder in Hispanic Vietnam veterans: Clinical phenomenology and sociocultural characteristics. Journal of Nervous and Mental Disease 171:585–596, 1983.

    Google Scholar 

  3. 3.

    Friedman MJ, Kolb LC, Arnold A, et al: Third annual report of the Chief Medical Director's Special Committee on Post Traumatic Stress Disorder, 1987.

  4. 4.

    Keane TM, Fairbank JA: Survey analysis of combat-related stress disorders in Vietnam veterans. American Journal of Psychiatry 140:348–350, 1983.

    Google Scholar 

  5. 5.

    McFall ME, MacKay RW, Donovon DM: Combat related PTSD and psychosocial adjustment problems among substance abusing veterans. Journal of Nervous and Mental Diseases 179:33–38, 1991.

    Google Scholar 

  6. 6.

    Sierles FS, Chen JJ, McFarland RE, et al: Post traumatic stress disorder and concurrent psychiatric illness: A preliminary report. American Journal of Psychiatry 140:1177–1179, 1983.

    Google Scholar 

  7. 7.

    Sierles FS, Chen JJ, Messing ML, et al: Concurrent psychiatric illness in non-Hispanic outpatients diagnosed as having post traumatic stress disorder. Journal of Nervous and Mental Disease 174:171–173, 1986.

    Google Scholar 

  8. 8.

    Health Status of Vietnam Veterans. Volume IV Psychological and Neuropsychological Evaluation. U.S. Department of Health and Human Services Public Health Service Center for Disease Control, Atlanta Georgia 1989, page 62.

  9. 9.

    Kulka RA, Schlenger WE, Fairbank JA, et al: Trauma and the Vietnam War generation. Bruner-Mazel 117–126, 1990.

  10. 10.

    Jordan BK, Schlenger WE, Hough R, et al: Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls. Archives of General Psychiatry 48:207–215, 1991.

    Google Scholar 

  11. 11.

    Fisher VJ: Combat exposure and the etiology of post discharge substance abuse problems among Vietnam veterans. Journal of Traumatic Stress 4:251–277, 1991.

    Google Scholar 

  12. 12.

    Helzer JE: The impact of combat on later alcohol use by Vietnam veterans. Journal of Psychoactive Drugs 16(2):183–191, 1984.

    Google Scholar 

  13. 13.

    Robins LN, Helzer JE, Davis DH: Narcotics use in Southeast Asia and afterwards. Archives of General Psychiatry 32:955–961, 1975.

    Google Scholar 

  14. 14.

    Regier DA, Farmer ME, Rae DS, et al: Co-morbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area Study. Journal of the American Medical Association 264:2511–2518, 1990.

    Google Scholar 

  15. 15.

    Kosten TR, Krystal J: Biological mechanisms in post traumatic stress disorder relevance for substance abuse. Recent Developments in Alcoholism 6:49–68, 1988.

    Google Scholar 

  16. 16.

    Green B, Lindy JD, Grace MC, et al: Multiple diagnosis in post traumatic stress disorder. The role of war stressors. The Journal of Nervous and Mental Diseases 177:329–335, 1989.

    Google Scholar 

  17. 17.

    Green BL, Grace MC, Goldine GC: Identifying survivors at risk: Long-term impairment following the Beverly Hills Supper Club fire. Journal of Consulting and Clinical Psychology 53:672–678, 1985.

    Google Scholar 

  18. 18.

    Yager T, Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. Archives of General Psychiatry 41:327–333, 1984.

    Google Scholar 

  19. 19.

    McCormick RA, Taber JI, Knuedelback N: The relationship between attributional style and post traumatic stress disorder in addicted patients. Journal of Traumatic Stress 2:477–487, 1989.

    Google Scholar 

  20. 20.

    Khantzian EJ: The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. The American Journal of Psychiatry 142:1259–1264, 1985.

    Google Scholar 

  21. 21.

    Lehman AF, Myers P, Corty E: Assessment and classification of patients with psychiatric and substance abuse syndromes. Hospital and Community Psychiatry 40:1019–1025, 1989.

    Google Scholar 

  22. 22.

    Lacoursiere RB, Godfrey KE, Ruby LM: Traumatic neurosis in the etiology of alcoholism: Vietnam combat and other trauma. American Journal of Psychiatry 137:966–968, 1980.

    Google Scholar 

  23. 23.

    Schnitt JM, Nocks JJ: Alcoholism treatment of Vietnam veterans with post traumatic stress disorder. Journal of Substance Abuse Treatment 1:179–189, 1984.

    Google Scholar 

  24. 24.

    Volpicelli JR: Uncontrollable events and alcohol drinking. British Journal of Addiction 82:381–392, 1987.

    Google Scholar 

  25. 25.

    McLellan AT, Luborsky L, Woody GE, et al: An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disease 168:26–33, 1980.

    Google Scholar 

  26. 26.

    McLellan 1983 McLellan AT, Luborsky L, Woody GE, et al: Predicting response to alcohol and drug abuse treatments. Archives of General Psychiatry 40:620–625, 1983.

    Google Scholar 

  27. 27.

    McLellan AT: Psychiatric severity as a predictor of outcome from substance abuse treatments, in Substance Abuse and Psychology. Edited by Alterman AI. New York, Plenum, 1985.

    Google Scholar 

  28. 28.

    Cummings CP, Prokop CK, Cosgrove, R: Dysphoria: The cause or the result of addiction? Psychiatric Hospital 16:131–134, 1985.

    Google Scholar 

  29. 29.

    Penick EC, Powell BJ, Liskow BL, et al: The stability of coexisting psychiatric syndromes in alcoholic men after one year. Journal of Studies on Alcohol 49:395–404, 1988.

    Google Scholar 

  30. 30.

    Rounsaville BJ, Dolinsky ZS, Babor TF, et al: Psychopathology as a predictor of treatment outcome in alcoholics. Archives of General Psychiatry 44:505–513, 1987.

    Google Scholar 

  31. 31.

    Woody GE, McLellan AT, Luborsky L, et al. Severity of psychiatric symptoms as a predictor of benefits from psychotherapy: The Veterans Administration—Penn study. Am J of Psychiatry 141:1172–1177, 1984.

    Google Scholar 

  32. 32.

    Kofoed L, Kania, J, Walsh T, et al: Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. American Journal of Psychiatry 143:867–872, 1986.

    Google Scholar 

  33. 33.

    Minkoff K: An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and Community Psychiatry 40:1031–1036, 1989.

    Google Scholar 

  34. 34.

    Osher FC, Kofoed LL: Treatment of patients with psychiatric and psychoactive substance abuse disorder. Hospital and Community Psychiatry 40:1025–1030, 1989.

    Google Scholar 

  35. 35.

    Keane TM, Wolfe J: Comorbidity in PTSD: An analysis of community and clinical studies. Journal of Applied Social Psychology 20,21:1776–1788, 1990.

    Google Scholar 

  36. 36.

    Yehuda R, Lowry MT, Southwick SM, et al: Lymphocyte glucocorticoid receptor number in post traumatic stress disorder. American Journal of Psychiatry 148:499–504, 1991.

    Google Scholar 

  37. 37.

    Friedman MJ: Psychobiology and pharmacological approaches to treatment, in International Handbook of Traumatic Stress Syndromes. Edited by Wilson JP, Raphael B. New York and London, Plenum Press, in press.

  38. 38.

    Mellman TA, Davis GC: Combat-related flashbacks in post traumatic stress disorder: Phenomenology and similarity to panic attacks. Journal of Clinical Psychiatry 46:379–382, 1985.

    Google Scholar 

  39. 39.

    Perry SW, Cella DF, Falkenberg J, et al: Pain perception in burn patients with stress disorders. Journal of Pain and Symptom Management 2:29–33, 1987.

    Google Scholar 

  40. 40.

    van der Kolk BA: The trauma spectrum; The interaction of biological and social events in the genesis of the trauma response. Journal of Traumatic Stress 1:273–290, 1988.

    Google Scholar 

  41. 41.

    Risse SC, Whitters A, Burke J, et al: Severe withdrawal symptoms after discontinuation of alprazolam in eight patients with combat-induced post traumatic stress disorder. Journal of Clinical Psychiatry 51:206–209, 1990.

    Google Scholar 

  42. 42.

    Boudewyns PA, Woods GM, Hyer L, et al: Chronic combat related PTSD and concurrent substance abuse, implications for treatment of this frequent dual diagnosis. Journal of Traumatic Stress: in press.

  43. 43.

    Abueg FR, Fairbank JA: Behavioral treatment of the PTSD-substance abuser: A multi-dimensional stage model in, Post Traumatic Stress Disorder: A Behavioral Approach to Assessment and Treatment. Edited by Saigh P, Permagon Press, in press.

  44. 44.

    Jellinek JM, Williams T: Post traumatic stress disorder and substance abuse in Vietnam combat veterans: Treatment problems, strategies and recommendations. Journal of Substance Abuse Treatment 1:87–97, 1984.

    Google Scholar 

  45. 45.

    Kofoed LL, Keys AL: Using group therapy to persuade dual diagnosis patients to seek treatment. Hospital and Community Psychiatry 39:120–1211, 1988.

    Google Scholar 

  46. 46.

    Bollerud K: A model for the treatment of trauma-related syndromes among chemically dependent inpatient women. Journal of Substance Abuse Treatment 7:83–87, 1990.

    Google Scholar 

  47. 47.

    Kuhne A, Nohner W: Efficacy of chemical dependency treatment as a function of combat in Vietnam. Journal of Substance Abuse Treatment 3:191–194, 1986.

    Google Scholar 

  48. 48.

    Friedman MJ: Interrelationship between biological mechanisms and pharmacotherapy of post traumatic stress disorder, in Post Traumatic Stress Disorder: Etiology, Phenomenology and Treatment. Edited by Wolf ME and Mosnaim AD. Washington, DC, American Psychiatry Press, 1990.

    Google Scholar 

  49. 49.

    Keane TM, Fairbank JA, Caddell JM: Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy 20:245–260, 1989.

    Google Scholar 

  50. 50.

    Brom D, Kleber RJ: Prevention of post traumatic stress disorders. Journal of Traumatic Stress 2:335–351, 1989.

    Google Scholar 

  51. 51.

    Friedman MJ: Biological approaches to the diagnosis and treatment of post traumatic stress disorder. Journal of Traumatic Stress 4:67–91, 1991.

    Google Scholar 

  52. 52.

    Ciraulo DA, Barnhill JG, Greenblatt DJ, et al. Abuse liability and clinical pharmaokinetics of alprazolam in alcoholic men. Journal of Clinical Psychiatry 49:333–337, 1988a.

    Google Scholar 

  53. 53.

    Ciraulo DA, Barnhill JG, Ciraulo AM, et al. Parental alcoholism as a risk factor in benzodiazepine abuse: a pilot study. American Journal of Psychiatry 146:1333–1335, 1989.

    Google Scholar 

  54. 54.

    Ciraulo DA, Sands BF, Shader RI. Critical review of liability for benzodiazepine abuse among alcoholics. American Journal of Psychiatry 145:1501–1506, 1988b.

    Google Scholar 

  55. 55.

    Gottschalk LA, Bates DE, Fox RA: et al. Psychoactive drug use; patterns found in samples from a mental health clinical and a general medical clinic. Archives of General Psychiatry 25:395–397, 1971.

    Google Scholar 

  56. 56.

    Hubbard B, Kripke DF. Hypnotic and minor tranquilizer use among inpatients and after discharge. International Journal of Addictions 11:403–408, 1986.

    Google Scholar 

  57. 57.

    Samarasinghe DS, Tilley S, Marks IM. Alcohol and sedative drug use in neurotic outpatients. British Journal of Psychiatry 145:45–48, 1984.

    Google Scholar 

  58. 58.

    Ashley MJ, le Riche W, Hatcher J, et al. ‘Mixed’ (drug abusing) and ‘pure’ alcoholics: a socio-medical comparison. British Journal of Addictions 73:19–34, 1978.

    Google Scholar 

  59. 59.

    Busto U, Simpkins MA, Sellers EM, et al. Objective determination of benzodiazepine use and abuse in alcoholics. British Journal of Addictions 73:429–435, 1983.

    Google Scholar 

  60. 60.

    Marlatt GA, Gordon JR: Relapse prevention, New York, Guilford Press, 1985.

    Google Scholar 

  61. 61.

    Raymond JS, Hurwitz S: Client preference-treatment congruence as a facilitation of length of stay: supporting an old altruism. International Journal of Addiction 16:431–441, 1981.

    Google Scholar 

  62. 62.

    Mayfield DG, McLeod G, Hall P: The CAGE questionnaire: Validation of a new alcoholism screening instrument. American Journal of Psychiatry 131:1121–1123, 1974.

    Google Scholar 

  63. 63.

    Ewing JA: Detecting alcoholism: The CAGE questionnaire. Journal of American Medical Association 252:1905–1907, 1984.

    Google Scholar 

  64. 64.

    Selzer ML: The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry 127:89–94, 1971.

    Google Scholar 

  65. 65.

    Magruder-Habib K, Harris KE, Fralzer GG: Validation of the Veterans Alcoholism Screening Test. Journal of Studies on Alcohol 43:910–926, 1982.

    Google Scholar 

  66. 66.

    Wanberg KW, Horn JL, Foster FM: A differential assessment model for alcoholism: The scales of the Alcohol Use Inventory; Journal of Studies on Alcohol 38:512–543, 1977.

    Google Scholar 

  67. 67.

    Annis HM, Graham JM, Davis CS: Inventory of Drinking Situation User's Guide, Toronto, Addiction Research Foundation, 1987.

    Google Scholar 

  68. 68.

    Brown SA, Goldman MS, Inn A; et al: Expectations of reinforcement from alcohol: Their domain and relation to drinking patterns. Journal of Consulting and Clinical Psychology 48:419–426, 1980.

    Google Scholar 

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Correspondence to Lial Kofoed M.D., M.S..

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Kofoed, L., Friedman, M.J. & Peck, R. Alcoholism and Drug Abuse in patients with PTSD. Psych Quart 64, 151–171 (1993).

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  • Public Health
  • Drug Abuse
  • Treatment Outcome
  • Treatment Approach
  • Effective Control