Dolores Vojvoda, MD Assistant Professor of Psychiatry, Yale School of Medicine
Dr. Vojvoda has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: We know PTSD often co-occurs with addiction. What should clinicians pay attention to? Dr. Vojvoda: Individuals who have PTSD have a high risk of developing other disorders, including substance use disorders (SUDs). Studies have shown that both in the veteran and non-veteran populations, these numbers are high. For example, one study of the general population found that alcohol use disorder (AUD) is the most common co-occurring disorder in men with PTSD (Kessler RC et al, Arch of Gen Psychiatry 1995;52(12):1048–1060). And a study in Vietnam veterans found that around 74% of combat veterans have an SUD (Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. New York, NY: Brunner/Mazel; 1990). And this goes in the other direction as well—when we look at treatment-seeking populations with SUDs, we find that the rates of comorbidity with PTSD are higher compared to the general population. So, almost 63% of veterans with an SUD have comorbid PTSD (Seal KH et al, J Gen Intern Med 2011;26(10):1160–1167).
CATR: The take-home message, then, is that it’s important to screen for these disorders. Dr. Vojvoda: Exactly. Now, the complicating factor is that it’s not only a matter of simple comorbidity—these impairments are more than the sum of their parts. Individuals that have both PTSD and SUDs have worse outcomes, including higher rates of other mental health disorders, medical problems, and functional impairment across multiple domains. They’re more likely to be unemployed, they’re more likely to be homeless, and they’re also more likely to be hospitalized. Also, patients who have comorbid PTSD and SUDs often end up having more severe PTSD symptoms than patients with PTSD alone. So, when treating this population, we must keep in mind that we are probably seeing people who will need more help for more severe symptoms than patients with PTSD or SUD alone.
CATR: As clinicians, we often wonder whether addiction leads to trauma or trauma leads to addiction. What are your thoughts? Dr. Vojvoda: I don’t have a definite answer for that. We do know that substance use and PTSD tend to go hand in hand, and it’s still unclear in which direction causality works. More importantly though, we know that co-occurrence increases severity of both disorders, and therefore we need to tackle both and not get derailed by overthinking which disorder came first. Historically, people were treating these disorders separately, even in different treatment settings, but now we find that such an approach is not as effective as the integrated treatment of both disorders.
CATR: Should treatment be provided by one clinician or by a team of clinicians who work together? Dr. Vojvoda: It can be either. For a while there was a perception that addressing trauma would make substance use worse. Clinicians were reluctant to do trauma-focused psychotherapy in dually diagnosed patients and would wait until the SUD got better, but that would often lead to patient dropout or relapse because factors that were driving substance use were still present. With the appreciation that postponing treatment of either disorder can lead to poorer outcomes for both, people are now treating both disorders simultaneously and having much better treatment outcomes.
CATR: How early can we provide this integrated approach in the recovery process? Dr. Vojvoda: In cases of patients with SUD who are at risk of withdrawal, detox and adequate medical stabilization need to be the first step in the treatment process. It is important to remember that PTSD can intensify the severity of withdrawal symptoms. But as soon as that acute phase of “detoxification” is over, we should start thinking of the best ways to integrate treatments. We know from several studies that trauma-focused psychotherapies can be tolerated even in the early phases of addiction treatment—there are a couple of studies with prolonged exposure (PE) and cognitive processing therapy (CPT) that were utilized along with psychotherapy for SUDs (Simpson TL et al, Alcohol Clin Exp Res 2017;41(4):681–702). We know from research that doing treatment this way benefits patients by reducing both PTSD symptoms and substance use.
CATR: Could you tell us more about trauma-focused psychotherapies? Dr. Vojvoda: Trauma-focused psychotherapies use different techniques to help process the traumatic experience and may involve talking, thinking, or visualizing the traumatic memory; they may also focus on changing distorted beliefs about the trauma. We have the strongest evidence right now for CPT, PE, and eye movement desensitization and reprocessing (EMDR). All three of them seem to be effective in addressing both acute and chronic PTSD symptoms. These are manualized treatments, usually between 8 and 16 sessions long, and the therapist requires training to provide them.
CATR: What are the main differences between these three therapies? Dr. Vojvoda: These therapies use cognitive, emotional, and behavioral techniques in the treatment of consequences of a traumatic event. Exposure to the traumatic event is a central to all these therapies. PE includes repeated exposure, both supervised recollection and in vivo, to the components of the traumatic event. CPT also includes a written exposure component but primarily focuses on modifying maladaptive beliefs about the trauma. And EMDR is also exposure-based and involves imaginal exposure to trauma accompanied by side-to-side eye movements or other bilateral stimuli like sound or hand tapping.
CATR: Is the eye-movement component to EMDR necessary, or is it just a gimmick? Dr. Vojvoda: EMDR has evolved over the years. The eye movement component was initially considered a crucial part of treatment. However, in recent years there has been increased evidence that the eye movements do not play a significant role in the effectiveness of EMDR. Regardless of this controversy, EMDR has shown strong evidence as an effective treatment for PTSD.
CATR: I’ve also heard that CPT works even without a prominent exposure element. Is that true? Dr. Vojvoda: CPT can be delivered with a written trauma account (CPT) or without a written trauma account (CPT-cognitive only, or CPT-C). It can be provided for patients who find it too difficult to talk about the trauma. Evidence shows that, in many cases, it is just as effective as the CPT with the exposure component (Walter KH et al, J Trauma Stress 2014;27(4):438–445).
CATR: We also hear about using mindfulness in treating PTSD. What are your thoughts on that? Dr. Vojvoda: Mindfulness-based psychotherapies have not been traditionally seen as treatments for PTSD, but they are gaining momentum, especially as adjunctive treatments. Mindfulness involves awareness of the present moment, and being non-judgmental and accepting. We don’t know empirically how effective these treatments are, but there are many reports of beneficial effects. Some patients find mindfulness helpful in regulating emotions and decreasing anxiety, depression, and impulsivity. It also helps with treatment engagement. And in people who are using substances, mindfulness may help cope with urges.
CATR: Should we start by evaluating what the patient can tolerate before offering trauma-focused psychotherapies? Dr. Vojvoda: Yes. The first step is to evaluate the needs of the patient sitting across from you. So, if you have a patient who is unsure about starting trauma-based treatments, or whose biggest problem is regulating emotions, or who is unsure about being able to follow through with the weekly treatment, you may want to start with a treatment that addresses those issues first. For example, we may recommend dialectical behavior therapy (DBT) as a first treatment step. DBT combines cognitive behavioral and mindfulness techniques and provides patients with skills to deal with emotion regulation, ruminative thinking, and urges to use substances. There are other treatments that also may be helpful in getting patients prepared for trauma-focused therapy. On the other hand, we find that many patients are ready to engage in the trauma-focused psychotherapy early in their treatment, so we should not hesitate to make such therapies available to them.
CATR: Let’s shift gears a bit and talk about meds. Are there any meds to consider or avoid alongside psychotherapy? Dr. Vojvoda: There currently are no medications that are proven to treat both PTSD and SUD. However, there are several effective medications for the treatment of PTSD and SUD when occurring alone, and they have shown some promise in treating this comorbidity. For example, if we have a patient with prominent PTSD symptoms, we will treat that patient with an SSRI, which is currently the most effective medication for trauma-related symptoms. Unfortunately, SSRIs do not improve alcohol use disorder (AUD) in the context of PTSD (Brady KS et al, J Clin Psychiatry 1995;56:502–505). But of course, there is evidence that medications like naltrexone and disulfiram improve outcomes in AUD. And so, the combination of an SSRI and one of those medications may be clinically appropriate in patients with comorbid PTSD and SUD.
CATR: So, would you say that SSRIs are a first-line treatment for PTSD, or are they best reserved for people who have not benefitted from a trauma-focused psychotherapy? Dr. Vojvoda: Clinical practice guidelines for PTSD have recommended both trauma-focused psychotherapies and SSRIs as effective treatments. However, the evidence for the effectiveness of trauma-focused psychotherapy for PTSD is stronger than for antidepressants. For a patient who is open to the idea of trauma-focused therapy, that should be the first-line treatment. However, we often see PTSD patients who have more complex presentations, including prominent depressive or anxiety symptoms. In such cases, we will initiate an SSRI right at the start of treatment, while still trying to engage the patient in the evidence-based therapy. There are also some patients who are not open to the idea of therapy, and for them an SSRI will be the treatment of choice. So, all treatment decisions need to be made in discussion with the patient.
CATR: And for a patient who is willing to engage in psychotherapy, would an SSRI add anything? Dr. Vojvoda: The most common treatment practice for patients with PTSD is combined medication and psychotherapy treatment. There still are many unanswered questions about choosing and combining treatments. For example, a recent study in combat veterans didn’t find a difference in PTSD outcomes between sertraline, PE, and their combination (Rauch SA, JAMA Psychiatry 2019;76(2):117–126).
CATR: Speaking of integrating meds with psychotherapy, there’s the PTSD-AUD paper from 2013 by Foa and coauthors (https://jamanetwork.com/journals/jama/article-abstract/1724275). I recall it looking at naltrexone, PE, and the combination for both PTSD and drinking outcomes. Your thoughts on the findings? Dr. Vojvoda: That was an interesting study, examining the efficacy of an evidence-based treatment for AUD (naltrexone) combined with an evidence-based treatment for PTSD (PE). Surprisingly, at the end of the study, PTSD severity was reduced across all treatment groups. Naltrexone was effective in reducing the severity of AUD, which was an expected outcome. At the 6-month follow-up, there was an increase in percentage of drinking in all treatment groups, but that increase was smallest in the PE and naltrexone group. This finding, for me, underlines the importance of treating PTSD and SUD simultaneously, as there seem to be long-term benefits for both disorders from such a treatment approach.
CATR: Interesting. Another medication we’ve been hearing about is prazosin. Dr. Vojvoda: Yes, anecdotal evidence and early studies of prazosin have shown great promise in the treatment of PTSD, especially in alleviating nightmares and improving sleep. As a result, prazosin was widely prescribed to patients with PTSD, especially in the VA system. Disappointingly, the most recent and largest study did not find prazosin to be effective in reducing nightmares and alleviating sleep disturbance. In another study, prazosin was not superior to placebo in reducing PTSD or AUD. Despite these findings, many psychiatrists continue to prescribe prazosin.
CATR: What about “traditional” meds for SUDs? Can they have any effect on reducing comorbid PTSD symptoms? Dr. Vojvoda: A 2006 study by Petrakis and others evaluated medications that have been successfully used in treatment of AUD, naltrexone and disulfiram, in patients with comorbid PTSD. Both medications showed evidence for improving PTSD symptoms in addition to improved drinking outcomes (Petrakis IL et al, Biol Psychiatry 2006;60(7):777–783). However, a more recent study of adjunctive naltrexone to antidepressant medication did not show an advantage for alcohol use outcomes or PTSD symptoms (Petrakis IL et al, Neuropsychopharmacology 2012;37(4):996–1004). At this point, the strongest evidence is for the anticonvulsant topiramate in a couple of studies that showed both a significant decrease in PTSD symptoms and a reduction in alcohol intake. Unfortunately, significant cognitive side effects limit topiramate use. We need more studies of these medications.
CATR: What are your thoughts on using benzos for PTSD? Dr. Vojvoda: They are best avoided. Benzos are not only contraindicated in terms of risk for substance misuse, they are also not beneficial for PTSD symptoms. If anything, they can increase the symptomology.
CATR: What about antipsychotics? Dr. Vojvoda: After several encouraging case reports and open studies of antipsychotics, most notably risperidone, there was hope that these medications could be used successfully in treatment of PTSD. However, a large, double-blind study did not support that (Krystal JH et al, JAMA 2011;306(5):493–502). At this time, we don’t think that there’s a role for antipsychotics in the treatment of patients with PTSD, unless they have associated psychotic symptoms.
CATR: Sometimes, re-experiencing is misdiagnosed as psychosis. Do you have any advice to help clinicians differentiate between the two? Dr. Vojvoda: Patients who are reporting re-experiencing symptoms typically have intact reality testing and are able to report the symptoms as reliving of a traumatic event.
CATR: Any additional advice for the busy clinician? Dr. Vojvoda: I’ll go back to the point about approaching the treatment of SUD and PTSD simultaneously but taking the patient’s preference into account when selecting treatment. We as clinicians are often eager to recommend what we believe are the most effective treatments. But starting trauma-focused evidence-based treatment in a patient who’s not ready is not helpful and can lead to dropout. The best treatment plans are developed with the patient’s input.