Treatment of Co-occurring Posttraumatic Stress Disorder and Substance Use Disorders

Abstract

There is a significant need for advanced understanding of treatment of co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Approximately half of individuals seeking SUD treatment meet criteria for current PTSD, and individuals with co-occurring PTSD-SUD tend to have poorer treatment outcomes compared with those without such comorbidity. However, there is not sufficient empirical evidence to determine a best course of treatment for these individuals. This paper provides a review of the literature relevant to the treatment of co-occurring PTSD-SUD. To date, treatment studies have focused primarily on non-exposure-based psychosocial treatments, exposure-based psychosocial treatments, and medication trials. The most promising outcome data thus far are for psychosocial treatments that incorporate an exposure therapy component; however, further research is needed, particularly as related to how best to implement these approaches in real-world treatment settings.

This is a preview of subscription content, access via your institution.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.

    Brady KT, Back S, Coffey SF. Substance abuse and posttraumatic stress disorder. Curr Dir Psychol Sci. 2004;13:206–9.

    Article  Google Scholar 

  2. 2.

    Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry. 1995;52:1048–60.

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Coffey SF, Saladin ME, Drobes DJ, Brady KT, Dansky BS, Kilpatrick DG. Trauma and substance cue reactivity in individuals with comorbid posttraumatic stress disorder and cocaine or alcohol dependence. Drug Alcohol Depend. 2002;65:115–27.

    PubMed  Article  Google Scholar 

  4. 4.

    Drapkin ML, Yusko D, Yasinski C, Oslin D, Hembree EA, Foa EB. Baseline functioning among individuals with posttraumatic stress disorder and alcohol dependence. J Subst Abuse Treat. 2011;41:186–92.

    PubMed  Article  Google Scholar 

  5. 5.

    Saladin ME, Drobes DJ, Coffey SF, Dansky BS, Brady KT, Kilpatrick DG. PTSD symptom severity as a predictor of cue-elicited drug craving in victims of violent crime. Addict Behav. 2003;28:1611–29.

    PubMed  Article  Google Scholar 

  6. 6.

    Simpson TL, Stappenbeck CA, Varra AA, Moore SA, Kaysen D. Symptoms of posttraumatic stress predict craving among alcohol treatment seekers: results of a daily monitoring study. Psychol Addict Behav. 2012.

  7. 7.

    Neale MC, Kendler KS. Models of comorbidity for multiractorial disorders. Am J Hum Genet. 1995;57:935–53.

    PubMed  CAS  Google Scholar 

  8. 8.

    Krueger RF, Markon KE. Reinterpreting comorbidity: a model-based approach to understanding and classifying psychopathology. Annu Rev Clin Psychol. 2006;2:111–33.

    PubMed  Article  Google Scholar 

  9. 9.

    Wolf EJ, Miller MW, Krueger RF, Lyons MJ, Tsuang MT, Koenen KC. Posttraumatic stress disorder and the genetic structure of comorbidity. J Abnorm Psychol. 2010;119:320–30.

    PubMed  Article  Google Scholar 

  10. 10.

    Kendler KS, Baker JH. Genetic influences on measures of the environment: a systematic review. Psychol Med. 2007;37:615–26.

    PubMed  Article  Google Scholar 

  11. 11.

    Stein MB, Jang KJ, Taylor S, Vernon PA, Livesley WJ. Genetic and environmental influences on trauma exposure and posttraumatic stress disorder: a twin study. Am J Psychiatry. 2002;159:1675–81.

    PubMed  Article  Google Scholar 

  12. 12.

    Amstadter AB, Aggen SH, Knudsen GP, Reichborn-Kjennerud T, Kendler KS. A population-based study of familial and individual-specific environmental contributions to traumatic event exposure and posttraumatic stress disorder symptoms in a Norwegian twin sample. Twin Res Human Genet. doi:10.1017/thg.2012.43.

  13. 13.

    McLeod DS, Koenen KC, Meyer JM, Lyons MJ, Eisen S, True W, et al. Genetic and environmental influences on the relationship among combat exposure, posttraumatic stress disorder symptoms, and alcohol use. J Trauma Stress. 2001;14:259–75.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Koenen KC, Lyons MJ, Goldberg J, Simpson J, Williams WM, Toomey R, et al. A co-twin control study of the relationship between combat exposure, combat-related posttraumatic stress disorder and other mental disorders. J Trauma Stress. 2003;16:433–8.

    PubMed  Article  Google Scholar 

  15. 15.

    Xian H, Chantarujikapong SI, Shrerrer JF, Eisen SA, Lyons MJ, Goldberg J, et al. Genetic and environmental influences on posttraumatic stress disorder, alcohol, and drug dependence in twin pairs. Drug Alcohol Depend. 2000;61:95–102.

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Kendler KS, Gardner CO, Prescott CA. Personality and the experience of environmental adversity. Psychol Med. 2003;33:1193–202.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Magnus K, Diener E, Fujita F, Pavot W. Extraversion and neuroticism as predictors of objective life events: a longitudinal analysis. J Pers Soc Psychol. 1993;65:1046–53.

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Holeva V, Tarrier N. Personality and peritraumatic dissociation in the prediction of PTSD in victims of road traffic accidents. J Psychosom Res. 2001;51:687–92.

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Marshall-Berenz EC, Vujanovic AA, Bonn-Miller MO, Bernstein A, Zvolensky MJ. Multimethod study of distress tolerance and PTSD symptom severity in a trauma-exposed community sample. J Trauma Stress. 2010;23:623–30.

    PubMed  Article  Google Scholar 

  20. 20.

    Parslow RA, Jorm AF, Christensen H. Associations of pre-trauma attributes and trauma exposure with screening positive for PTSD: analysis of a community-based study of 2,085 young adults. Psychol Med. 2006;36:387–95.

    PubMed  Article  Google Scholar 

  21. 21.

    Sintov ND, Kendler KS, Walsh D, Patterson DG, Prescott CA. Predictors of illicit substance dependence among individuals with alcohol dependence. J Stud Alcohol Drugs. 2009;70:269–78.

    PubMed  Google Scholar 

  22. 22.

    Heath AC, Bucholz KK, Madden PA, Dinwiddie SH, Slutske WS, Bierut LJ, et al. Genetic and environmental contributions to alcohol dependence risk in a national twin sample: consistency of findings in women and men. Psychol Med. 1997;27:1381–96.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282:755–62.

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    Kaysen D, Simpson T, Dillworth T, Larimer ME, Gutner C, Resick PA. Alcohol problems and posttraumatic stress disorder in female crime victims. J Trauma Stress. 2006;19:399–403. doi:10.1002/jts.20122.

    PubMed  Article  Google Scholar 

  25. 25.

    Chilcoat HD, Breslau N. Investigations of causal pathways between PTSD and drug use disorders. Addict Behav. 1998;23:827–40.

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Chilcoat HD, Breslau N. Posttraumatic stress disorder and drug disorders: testing causal pathways. Arch Gen Psychiatry. 1998;55:913–7.

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Kilpatrick DG, Acierno R, Resnick HS, Saunders BE, Best CL. A 2-year longitudinal analysis of the relationship between violent assault and substance abuse in women. J Consult Clin Psychol. 1997;65:834–47.

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Kaysen D, Neighbors C, Martell J, Fossos N, Larimer ME. Incapacitated rape and alcohol use: a prospective analysis. Addict Behav. 2006;31:1820–32.

    PubMed  Article  Google Scholar 

  29. 29.

    Messman-Moore TL, Ward RM, Brown AL. Substance use and PTSD symptoms impact the likelihood of rape and revictimization in college women. J Interpers Violence. 2009;24:499–521.

    PubMed  Article  Google Scholar 

  30. 30.

    Khantzian EJ. Treating addiction as a human process. Northvale, NJ: Jason Aronson; 1999.

    Google Scholar 

  31. 31.

    Mellman TA, Randolph CA, Brawman-Mintzer O, Flores LP, Milanes FJ. Phenomenology and course of psychiatric disorders associated with combat related posttraumatic stress disorder. Am J Psychiatry. 1992;149:1568–74.

    PubMed  CAS  Google Scholar 

  32. 32.

    Waldrop AE, Back SE, Verduin ML, Brady KT. Triggers for cocaine and alcohol use in the presence and absence of posttraumatic stress disorder. Addict Behav. 2007;32:634–9.

    PubMed  Article  Google Scholar 

  33. 33.

    O'Hare T, Sherrer M. Drinking motives as mediators between PTSD symptom severity and alcohol consumption in persons with severe mental illnesses. Addict Behav. 2011;36:465–9.

    PubMed  Article  Google Scholar 

  34. 34.

    • Coffey SF, Schumacher JA, Stasiewicz PR, Henslee AM, Baillie LE, Landy N. Craving and physiological reactivity to trauma and alcohol cues in posttraumatic stress disorder and alcohol dependence. Exp Clin Psychopharmacol. 2010;18:340–9. PTSD symptoms decrease during a period of abstinence from substances, even when no PTSD treatment is provided.

    PubMed  Article  Google Scholar 

  35. 35.

    Back SE, Brady KT, Jaanimagi U, Jackson JL. Cocaine dependence and PTSD: a pilot study of symptom interplay and treatment preferences. Addict Behav. 2006;31:351–4.

    PubMed  Article  Google Scholar 

  36. 36.

    Brown PJ, Stout RL, Gannon-Rowley J. Substance use disorder-PTSD comorbidity. Patients' perceptions of symptom interplay and treatment issues. J Subst Abuse Treat. 1998;15:445–8.

    PubMed  Article  CAS  Google Scholar 

  37. 37.

    Back SE, Brady KT, Sonne SC, Verduin ML. Symptom improvement in co-occurring PTSD and alcohol dependence. J Nerv Ment Dis. 2006;194:690–6.

    PubMed  Article  Google Scholar 

  38. 38.

    Coffey SF, Schumacher JA, Brady KT, Cotton BD. Changes in PTSD symptomatology during acute and protracted alcohol and cocaine abstinence. Drug Alcohol Depend. 2007;87:241–8.

    PubMed  Article  Google Scholar 

  39. 39.

    Najavits LM, Weiss RD, Shaw SR, Muenz LR. "Seeking safety": Outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence. J Trauma Stress. 1998;11:437–56.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Herman JL. Trauma and recovery. New York: Basic Books; 1992.

    Google Scholar 

  41. 41.

    Najavits LM. Seeking safety: a treatment manual for PTSD and substance abuse. New York: Guilford Press; 2002.

    Google Scholar 

  42. 42.

    Norman SB, Wilkins KC, Tapert SF, Lang AJ, Najavits LM. A pilot study of seeking safety therapy with OEF/OIF veterans. J Psychoactive Drugs. 2010;42:83–7.

    PubMed  Article  Google Scholar 

  43. 43.

    Lynch SM, Heath NM, Mathews KC, Cepeda GJ. Seeking safety: an intervention for trauma-exposed incarcerated women? J Trauma Dissociation. 2012;13:88–101.

    PubMed  Article  Google Scholar 

  44. 44.

    • Hien DA, Wells EA, Jiang H, Suarez-Morales L, Campbell AN, Cohen LR, et al. Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. J Consult Clin Psychol. 2009;77:607–19. Seeking Safety did not differ from a women's health education control group in predicting PTSD and SUD outcomes.

    PubMed  Article  Google Scholar 

  45. 45.

    Hien DA, Cohen LR, Miele GM, Litt LC, Capstick C. Promising treatments for women with comorbid PTSD and substance use disorders. Am J Psychiatry. 2004;161:1426–32.

    Google Scholar 

  46. 46.

    Zlotnick C, Johnson J, Najavits LM. Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD. Behav Ther. 2009;40:325–36.

    PubMed  Article  Google Scholar 

  47. 47.

    Boden MT, Kimerling R, Jacobs-Lentz J, Bowman D, Weaver C, Carney D, et al. Seeking safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction. 2012;107:578–86.

    PubMed  Article  Google Scholar 

  48. 48.

    Donovan B, Padin-Rivera E, Kowaliw S. "Transcend": initial outcomes from a posttraumatic stress disorder/substance abuse treatment program. J Trauma Stress. 2001;14:757–72.

    PubMed  Article  CAS  Google Scholar 

  49. 49.

    McGovern MP, Lambert-Harris C, Acquilano S, Xie H, Alterman AI, Weiss RD. A cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders. Addict Behav. 2009;34:892–7.

    PubMed  Article  Google Scholar 

  50. 50.

    McGovern MP, Lambert-Harris C, Alterman AI, Xie H, Meier A. A randomized controlled trial comparing integrated cognitive behavioral therapy versus individual addiction counseling for co-occurring substance use and posttraumatic stress disorders. J Dual Diagn. 2011;7:207–27.

    PubMed  Article  Google Scholar 

  51. 51.

    • Foa EB, Hembree EA, Rothbaum BO. Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences. New York: Oxford University Press; 2007. Prolonged Exposure therapy manual for the treatment of PTSD.

    Google Scholar 

  52. 52.

    • Foa EB, Keane TM, Friedman MJ, editors. Effective treatments for PTSD: practice guidelines from the international society for traumatic stress studies. 2nd ed. New York: Guilford Press; 2008. Names Prolonged Exposure and Cognitive Processing Therapy as effective psychosocial treatments for PTSD.

  53. 53.

    • Powers MB, Halpern JM, Ferenschak MP, Gillihan SJ, Foa EB. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clin Psychol Rev. 2010;30:635–41. Prolonged exposure is an effective and lasting treatment for PTSD.

    PubMed  Article  Google Scholar 

  54. 54.

    Triffleman E. Gender differences in a controlled pilot study of psychosocial treatments in substance dependent patients with posttraumatic stress disorder: design considerations and outcomes. Alcohol Treat Q. 2000;18:113–26.

    Article  Google Scholar 

  55. 55.

    Back SE, Dansky BS, Carroll KM, Foa EB, Brady KT. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: description of procedures. J Subst Abuse Treat. 2001;21:35–45.

    PubMed  Article  CAS  Google Scholar 

  56. 56.

    Brady KT, Dansky BS, Back SE, Foa EB, Carroll KM. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings. J Subst Abuse Treat. 2001;21:47–54.

    PubMed  Article  CAS  Google Scholar 

  57. 57.

    Monti PM, Abrams DB, Kadden RM, Cooney NL. Treating alcohol dependence. New York: Guilford Press; 1989.

    Google Scholar 

  58. 58.

    Najavits LM, Schmitz M, Gotthardt S, Weiss RD. Seeking safety plus exposure therapy: an outcome study on dual diagnosis men. J Psychoactive Drugs. 2005;37:425–35.

    PubMed  Article  Google Scholar 

  59. 59.

    Coffey SF, Stasiewicz PR, Hughes PM, Brimo ML. Trauma-focused imaginal exposure for individuals with comorbid posttraumatic stress disorder and alcohol dependence: revealing mechanisms of alcohol craving in a cue reactivity paradigm. Psychol Addict Behav. 2006;20:425–35.

    PubMed  Article  Google Scholar 

  60. 60.

    Ouimette P, Moos RH, Finney JW. PTSD treatment and 5-year remission among patients with substance use and posttraumatic stress disorders. J Consult Clin Psychol. 2003;71:410–4.

    PubMed  Article  Google Scholar 

  61. 61.

    Brady KT, Sonne S, Anton RF, Randall CL, Back SE, Simpson K. Sertraline in the treatment of co-occurring alcohol dependence and posttraumatic stress disorder. Alcohol Clin Exp Res. 2005;29:395–401.

    PubMed  Article  CAS  Google Scholar 

  62. 62.

    Petrakis IL, Poling J, Levinson C, Nich C, Carroll K, Ralevski E, et al. Naltrexone and disulfiram in patients with alcohol dependence and comorbid post-traumatic stress disorder. Biol Psychiatry. 2006;60:777–83.

    PubMed  Article  CAS  Google Scholar 

  63. 63.

    Alderman CP, McCarthy LC, Condon JT, Marwood AC, Fuller JR. Topiramate in combat-related posttraumatic stress disorder. Ann Pharmacother. 2009;43:635–41.

    PubMed  Article  CAS  Google Scholar 

  64. 64.

    Petrakis IL, Ralevski E, Desai N, Trevisan L, Gueorguieva R, Rounsaville B, et al. Noradrenergic vs serotonergic antidepressant with or without naltrexone for veterans with PTSD and comorbid alcohol dependence. Neuropsychopharmacology. 2012;37:996–1004.

    PubMed  Article  CAS  Google Scholar 

  65. 65.

    • Norman SB, Myers US, Wilkins KC, Goldsmith AA, Hristova V, Huang Z, et al. Review of biological mechanisms and pharmacological treatments of comorbid PTSD and substance use disorder. Neuropharmacology. 2012;62:542–51. This article reviews pharmacological treatments of PTSD-SUD and provides important insights for future directions in the field.

    PubMed  Article  CAS  Google Scholar 

  66. 66.

    Riggs DS, Foa EB. Treatment for co-morbid posttraumatic stress disorder and substance use disorders. In: Stewart SH, Conrad PJ, editors. Anxiety and substance use disorders: the vicious cycle of comorbidity. New York: Springer; 2008. p. 119–37.

    Google Scholar 

  67. 67.

    Coffey SF, Schumacher JA, Stasiewicz PR. Prolonged exposure for the treatment of PTSD in a PTSD-alcohol dependent sample. 35th Annual Scientific Meeting of the Research Society on Alcoholism; San Francisco, CA. 2012.

  68. 68.

    Resick PA, Schnicke MK. Cognitive processing therapy for rape victims: a treatment manual. Newbury Park, CA: Sage; 1996.

    Google Scholar 

Download references

Acknowledgements

This manuscript was supported, in part, by National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant R01AA016816 (PI: S. F. Coffey).

Disclosure

E. C. Berenz: none; S. F. Coffey: grants from National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and Department of Veterans Affairs and consultant to National Institute on Alcohol Abuse and Alcoholism/University of Washington and National Institute on Drug Abuse/Medical University of South Carolina.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Scott F. Coffey.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Berenz, E.C., Coffey, S.F. Treatment of Co-occurring Posttraumatic Stress Disorder and Substance Use Disorders. Curr Psychiatry Rep 14, 469–477 (2012). https://doi.org/10.1007/s11920-012-0300-0

Download citation

Keywords

  • Posttraumatic stress disorder
  • PTSD
  • Substance use
  • Substance abuse
  • Substance dependence
  • Addiction
  • Alcohol
  • Alcoholism
  • Cocaine
  • Prolonged exposure
  • Comorbidity
  • Anxiety
  • Treatment
  • Selective serotonin reuptake inhibitors
  • SSRI
  • Cognitive behavioral therapy
  • CBT