Dual Diagnosis: PTSD and Alcohol Abuse
By Lee Hyer, Edward McCranie, and Lynne Peralme
NCP Clinical Newsletter 3(3-4): Summer/Fall 1993
Pavese said that "To know the world, one must construct it." From what has the conjoint world of PTSD and alcohol abuse been constructed? If its foundation is unsubstantiated clinical wisdom, professional bias, and non-existent empirical data, what do we really know about vulnerability factors related to dual diagnosis? What do we know about effective assessment devices and treatment packages developed to unearth and resolve the interactive and murky problems of trauma victims? This report addresses epidemiology, provides some "temporary truths" concerning the interactive dynamic of PTSD and alcohol abuse, and offers recommendations for assessment and treatment.
Using structured diagnostic interviews based on DSM-III criteria (American Psychiatric Association, 1980, 1987), studies conducted over the past decade have examined the co-morbidity of PTSD and alcohol abuse (or dependence) in both clinical and community samples of Vietnam veterans. In treatment-seeking veteran samples, reported rates of co-morbidity for current alcohol abuse or dependence range from 26 to 76 percent, and co-morbid rates for PTSD and lifetime prevalence of alcohol abuse or dependence range from 68 to 82 percent (see Hyer, 1993). From community surveys of Vietnam veterans, 22% (Kulka et al., 1990) and 39% (Centers for Disease Control, 1988) of veterans with current PTSD also exhibited current alcohol abuse or dependence. In the latter study 75% received a lifetime diagnosis of alcohol abuse or dependence. Finally, PTSD is prevalent in substance abuse units with rates of PTSD at 46% based on the MMPI-PTSD scale (Hyer et al., 1991) and comparable rates of symptom problems based on the Mississippi Scale (McFall et al., 1991); and alcohol abuse exists in PTSD units--of 100 PTSD patients at our facility, 35 percent had scores on the MCMI reflective of alcoholism (47% with alcohol problems).
Given such high co-morbidity, perhaps no more accurate statement regarding the interface between PTSD and alcohol problems exists than that they are "inextricably intertwined" (Boudewyns et al., 1991). Degree of combat exposure has been identified as related to the risk of developing both PTSD and alcohol problems (see Boudewyns et al., 1991); however, the strength of the relationship is influenced by other mediating factors (e.g., personality) and reexperiencing or avoidant symptoms may be differentially related to alcohol or substance abuse (McFall et al., 1992). Unless distinct causal, chronological relationships are found to exist, however, it may be an exercise in futility to focus on the degree to which premorbid variables (e.g., premilitary alcohol use and younger age in combat) and post-trauma factors (e.g., alcohol abuse, poor coping, and current stressors)‚ are sufficiently explanatory themselves or incrementally increase the amount of variance accounted for beyond that associated with the duration and severity of combat exposure.
Assessment
DSM-III-R criteria maximally differentiate among competing diagnoses but do not take into account interactive effects or provide criteria for co-occurring disorders, such as PTSD and alcohol abuse. The clinician is forced to measure each separately without knowing how the interactive effects of the two disorders may alter their thresholds. It is possible, for example, that an individual meeting criteria for alcohol abuse does not currently meet criteria for PTSD because the reexperiencing symptoms of the disorder have been suppressed by the alcohol. In such a case, would it be appropriate to lower the threshold for a PTSD diagnosis?
We cautiously present four recommendations for assessment, based on the "truth" that accurate and comprehensive diagnostic evaluations evolve from a multisource-multimethod approach. First, the clinician is advised to assess alcohol abuse in the context of PTSD problems over time , for the relative potency of each disorder and possible underlying reasons for each, such as avoidance (Penk et al., 1988) or sensation seeking (Solursh, 1989), will manifest themselves with time. Furthermore, since many PTSD victims are overreporters of symptoms (Hyer, 1993) and many alcohol abusers are given to denial (Bolo, 1991), the intriguing interaction between these two response styles can be better understood if measures are broad and continuous.
Second, since the certainty of any clinical decision is only as good as the criteria and method used in its formation, it is noted that the diagnostic reliability of PTSD and alcohol abuse both suffer from the retrospective nature of the data, mood dependent states, secondary gains, and memory deficits, as well as psychometric issues like unreliability (Bryant et al., 1992). Nevertheless, from the darkness of this reality emerge two measures, MacAndrew Alcoholism scale (MAC or MAC-R) (MacAndrew, 1965) and Alcohol Use Inventory (AUI) (Horn et al., 1986). The MAC may be used as a screening instrument and, although sensitive to general adjustment (Green, 1991), has a sensitivity rate at this medical center (for 100 PTSD vets with documented alcohol abuse) of 89%. Depending upon the patient's capacity for self-disclosure, the AUI can be an extremely helpful instrument for providing information on the central concern of substance abuse in PTSD patients, which pertains to their reasons for alcohol use.
Third, a non-PTSD/alcohol measure is endorsed, the University of Rhode Island Change Assessment Scale (URICA) (Prochaska & DiClemente, 1986). Based on the idea that change represents a "process," this scale has been used on addicted populations to assess behavioral and motivational change and as a measure of treatment readiness in a group with various levels of PTSD problems (Clanton, 1992).
Fourth, measurement of personality is recommended. A delicate balance exists in parsing apart the relative influence of trauma and alcohol in causing problems and the role played by vulnerability factors in determining symptom expression. Use of personality scales (e.g., MCMI or MCMI-II) has amply documented the absence of a unitary (alcoholic) personality and the presence of several clusters or subtypes of alcohol abusers, differences between alcohol abusers and other substance abusers, as well as differential treatment efficacy rates as a result of personality style (see Choca et al., 1992). Evaluating 250 confirmed PTSD cases, data at this center revealed personality style differences for groups above and below threshold for Alcohol Abuse on the MCMI; high alcohol group showing higher levels of Passive-Aggressive, Avoidant and Borderline scale scores.
Treatment
Traditionally, three models have guided the treatment of PTSD victims who abuse alcohol. The self medication model (see Boudewyns et al., 1991; Brinson & Treanor, 1988) holds that alcohol or other substances relieve PTSD symptoms (at least initially) and induce sleep. Accordingly, anxiety, irritability, and depression (sometimes) are suppressed. Over time, of course, alcohol tolerance works in the other direction: PTSD symptoms are not quelled and increased alcohol use occurs leading to alcoholism.
The second model holds that alcoholism is primary. Evidence for this position shows that drinking existed before combat (Helzer, 1984), that drinking started while in combat and continued (see Boudewyns et al., 1991), that risk factors related to alcohol abuse, such as family history of abuse (Davidson et al., 1989), are present, that drinking typically begins before trauma problems (Davidson et al., 1990), or that substance abuse is the first priority in any treatment (Nace, 1988).
Thirdly, a co-morbid model (Boudewyns et al., 1991; Wedding, 1987) endorsing integrated care requests that the safest road be traveled: Treat both.
Given the right circumstances, any of the models apply. Studies on the pre-combat psychosocial characteristics of veterans, alcohol/substance abuse patterns during combat, post-war abuse patterns, and their relationship to the course and current presentation of dual disorders are needed (Abueg & Fairbank, 1992). In fact, an evaluation of the interaction between only "PTSD" anxiety and alcohol use in PTSD subjects would be exceedingly helpful, since past research (Abueg & Fairbank, 1992) has found one or the other to exert a greater influence on continued substance abuse.
Until there is more clarity, we provide a guiding "truth" and one corollary. The "truth" is really a consensus: Treatment must begin with abstinence. While ultimately the treatment of either PTSD or alcohol abuse is a matter of timing, neither can be meaningfully initiated without commitment to abstinence. The presence of substance abuse before, during, or after treatment is a strong negative predictor of outcome (see Boudewyns et al., 1991). The corollary attends to the "reality" of the modal PTSD patient who commonly abuses substances. It posits that the relative importance of PTSD and substance abuse should involve therapeutic deliberations around the treatment factors of readiness/motivation for therapy and self-efficacy. Excessive therapeutic rigidity may disrupt the longer term goals of care.
This brief review has ignored many important issues. Primary issues related to categorization, such as order of symptom development, relationships of PTSD symptom profiles and alcohol use, role of primary or secondary alcoholism in trauma problems, treatment outcome issues, etc., and secondary issues, addressing moderating variables, especially race and combat exposure (Penk et al., 1988), cognitive deficits among adult alcoholics (Wolfe & Charney, 1991), "addiction to trauma" hypotheses (Bell & Khantzian, 1991), other co-morbid symptoms (especially depression) and their "role" in PTSD and alcoholism, among many others, have been left out. Despite the fact that the status of our art/science regarding this type of dual diagnosis is suspect, we can be more than mediocre in our response. Clear thinking, however, requires a reasoned tolerance for doubt, not an allegiance to any credo. Let the clinician beware.
References
Abueg, F., & Fairbank, J. (1992). Behavioral treatment of posttraumatic stress disorder and co-occurring substance abuse. In P.A. Saigh (Ed.) Posttraumatic Stress Disorder (pp. 111-146). New York: MacMillan Publishing.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed.-revised). Washington, DC: Author.
Bell, C. & Khantzian, E. (1991). Drug use and addiction as self-medication: A psychodynamic perspective. In M. Gold and A. Slaby (Eds.), Dual diagnosis in substance abuse (pp. 185-204). New York: Dekker Press.
Bolo, P. (1991). Substance abuse and anxiety disorders. In M. Gold & A. Slaby (Eds.), Dual diagnosis in substance abuse, (pp. 45-56). New York: Dekker Press.
Brinson, T., & Treanor, V. ( 1988). Alcoholism and post traumatic stress disorder among combat Vietnam veterans. Alcoholism Treatment Quarterly, 5(3/4), 65-82.
Boudewyns, P.A., Woods, M.G., Hyer, L., & Albrecht, J.W. (1991). Chronic combat-related PTSD and concurrent substance abuse: Implications for treatment of this frequent "dual diagnosis". Journal of Traumatic Stress, 4, 549-560.
Bryant, K.J., Rounsaville, B., Spitzer, R.L., Williams, J.B. (1992). Reliability of dual diagnosis substance dependence and psychiatric disorders. Journal of Nervous and Mental Disease, 180(4), 251-257.
Centers for Disease Control (1988). Health status of Vietnam veterans I. Psychosocial characteristics. Journal of the American Medical Association, 259, 2701-2702.
Choca, J., Shanley, L., & van Denburg, E. (1992). Interpretative guide to the Million Clinical Multiaxial Inventory. Washington, DC: American Psychiatric Association Press.
Clanton, L. (1992). Stages of change profiles and learned resourcefulness in a help seeking addicted population. Unpublished Dissertation. University of Georgia; Athens, Georgia.
Davidson, J.R., Kudler, H.S., Saunders, W.S., & Smith, R.D. (1990). Symptom and comorbidity patterns in World War II and Vietnam veterans with posttraumatic stress disorder. Comprehensive Psychiatry, 31, 162-170.
Davidson, J.R., Smith, R.D., & Kudler, H.S. (1989). Familial psychiatric illness in chronic post-traumatic stress disorder. Comprehensive Psychiatry, 30, 339-345.
Green, R. (1991). The MMPI-2/MMPI: An interpretive manual. New York: Allyn & Bacon.
Helzer, J. (1984). The impact of combat on later alcohol use by Vietnam veterans. Journal of Psychoactive Drugs, 16, 173-191
Horn, J.L., Wanberg, K.W., Foster, F.M. (1986). Alcohol Use Inventory. National Computer Systems, MN.
Hyer, L. (1993). The victim of trauma: Theoretical considerations and practical suggestions. Muncie, IN: Accelerated Press.
Hyer, L., Leach, P., Boudewyns, P., & Davis, H. (1991). "Hidden" posttraumatic stress disorder among substance abuse veterans. Journal of Clinical Psychology, 46(6), 718-722.
Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., & Weiss, D.S. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
MacAndrew, C. (1965). The differentiation of male alcoholic outpatients from non-alcoholic psychiatric outpatients by means of the MMPI. Quarterly Journal of Studies on Alcohol, 26, 238-246.
McFall, M.E., Mackay, P.W., & Donovan, D.M. (1992). Combat-related posttraumatic stress disorder and severity of substance abuse in Vietnam veterans. Journal of Studies on Alcohol, 53(4), 357-363.
McFall, M.E., Mackay, P.W., & Donovan, D.M. (1991). Combat-related PTSD and psychosocial adjustment problems among substance abusing veterans. Journal of Nervous and Mental Disease, 197 (1), 33-37.
Nace, E.P. (1988). Posttraumatic stress disorder and substance abuse: Clinical issues. In M. Galanter (Ed.) Recent developments in alcoholism, Volume 6 (pp. 9-26). New York: Plenum.
Penk, W., Peck, R., Robinowitz, R., Bell, W., & Little, D. (1988). Coping and defending styles among Vietnam combat veterans seeking treatment for Posttraumatic Stress Disorder and substance abuse disorders. In M. Galanter (Ed.), Recent developments in alcoholism, Volume 6 (pp. 71-88). New York: Plenum.
Prochaska, J., & DiClemente, C. (1986). The transtheoretical approach. In J.C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 163-200). New York: Brunner/Mazel.
Solursh, L. (1989). Combat addiction: Overview of implications in symptom maintenance and treatment planning. Journal of Traumatic Stress, 3 (4), 451-462.
Wedding, D. (1987). Substance abuse in the Vietnam veteran. AAOHN Journal, 35, 74-76.
Wolfe, J., & Charney, D. (1991). Use of neuropsychological assessment in Posttraumatic Stress Disorder. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 573-580.
|
