Bonnie S. Dansky

Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings

Individuals (n = 39) participated in an outpatient, 16-session individual, manual-guided psychotherapy designed to treat concurrent PTSD and cocaine dependence. Therapy consisted of a combination of imaginal and in-vivo exposure therapy techniques to treat PTSD symptoms and cognitive-behavioral techniques to treat cocaine dependence. Although the dropout rate was high, treatment completers (i.e., patients who attended at least 10 sessions; n = 15) demonstrated significant reductions in all PTSD symptom clusters and cocaine use from baseline to end of treatment. Significant reductions in depressive symptomatology, as measured by the Beck Depression Inventory, and psychiatric and cocaine use severity, as measured by the Addiction Severity Index, were also observed. These improvements in PTSD symptoms and cocaine use were maintained over a 6-month follow-up period among completers. The average pre- to posttreatment effect size was 1.80 for PTSD symptoms and 1.26 for drug and alcohol use severity. Baseline comparisons between treatment completers and noncompleters revealed significantly higher avoidance symptoms, as measured by the Impact of Events Scale, and fewer years of education among treatment noncompleters as compared to completers. This study provides preliminary evidence to suggest that exposure therapy can be used safely and may be effective in the treatment of PTSD in some individuals with cocaine dependence. However, the study is limited by the uncontrolled nature of the study design, small number of subjects, and high dropout rate.

Relationship of Childhood Sexual Abuse and Eating Disorders

OBJECTIVE To review the literature that has examined the relationship between childhood sexual abuse and the eating disorders. METHOD Each of the five authors reviewed all identified empirical studies to be certain that inclusion/exclusion criteria were met. Two teams of raters then independently reviewed each study to determine whether it supported any of a series of six hypotheses that had been tested in this literature. RESULTS This review indicates that childhood sexual abuse is a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. There is some indication that childhood sexual abuse is more strongly associated with bulimic disorders than restricting anorexia, but it does not appear to be associated with severity of the disturbance. CONCLUSION Childhood sexual abuse is a risk factor for bulimia nervosa with significant comorbidity. Further study of the nature of this relationship is warranted.

Understanding comorbidity between ptsd and substance use disorders: Two preliminary investigations☆

While there is high level of comorbidity of PTSD and substance use disorders (SUDs), little research has focused on the overlapping symptom constellation characteristic of both PTSD and substance use/withdrawal. This report describes two preliminary investigations that address this area. In the first study, the pattern of PTSD symptoms in a sample of women (n = 28) seeking treatment for a SUD and comorbid with PTSD was compared with the symptom pattern of a sample of women (n = 28) with PTSD only. The PTSD + SUD group evidenced significantly more symptoms in the avoidance and arousal symptom clusters than the PTSD-only group. At the individual symptom level, the PTSD + SUD group reported significantly more sleep disturbance than the PTSD-only group. It was also determined that the PTSD + SUD group reported greater traumatic-event exposure than the PTSD-only group. In the second study, PTSD symptoms were compared in a sample of alcohol- dependent and a sample of cocaine-dependent individuals with PTSD. The alcohol- dependent group exhibited significantly more arousal symptoms than the cocaine-dependent group. Implications of the results for the assessment of individuals with comorbid PTSD and SUDs are discussed.

The National Women's Study: relationship of victimization and posttraumatic stress disorder to bulimia nervosa.

OBJECTIVE In recent years there has been increased interest regarding the role of crime victimization in the development and/or maintenance of eating disorders, particularly bulimia nervosa. METHOD To examine the relationship among assault, bulimia nervosa, and binge eating disorder, a national, representative sample of 3,006 women completed structured telephone interviews. RESULTS Lifetime prevalence of completed, forcible rape for respondents with bulimia nervosa was 26.6%, as compared with 11.5% for respondents with binge eating disorder and 13.3% for respondents without bulimia nervosa or binge eating disorder. Compared to respondents without bulimia nervosa or binge eating disorder, aggravated assault history was significantly more prevalent in women with bulimia nervosa (26.8%), as was a lifetime history of posttraumatic stress disorder (36.9%). Characteristics of sexual assault experiences were not associated with dysfunctional eating patterns. Specific types of disordered eating such as compensatory behaviors in bulimia nervosa were associated with higher rates of victimization. CONCLUSIONS In sum, the significantly higher rates of both sexual and aggravated assault among women with bulimia nervosa compared with women without such a diagnosis support the hypothesis that victimization may contribute to the development and/or maintenance of bulimia nervosa.

Prevalence of victimization and posttraumatic stress disorder among women with substance use disorders: comparison of telephone and in-person assessment samples.

A structured interview with behaviorally specific probes was used to assess victimization and posttraumatic stress disorder (PTSD) in a clinical and a national, epidemiologic sample of women who had received treatment for a substance use disorder. Separate clinical and epidemiologic approaches to evaluating substance use disorders were compared. More than 80% of women in both samples had a history of sexual and/or physical assault and approximately one-quarter had current PTSD. The similarity in patterns of victimization, PTSD, and substance use across two samples suggests that telephone structured interviews are a valid method of collecting data/information about these important phenomena.

Comorbid Substance Abuse and Posttraumatic Stress Disorder: Characteristics of Women in Treatment

To further explore the complex relationship between posttraumatic stress disorder (PISD) and substance use disorders, the authors compared 30 women with PTSD in substance abuse treatment with 25 women without PTSD in substance abuse treatment on degree of addiction severity, psychopa-thology, and aftercare compliance. Women with PTSD were more likely to have been victims of sexual and physical abuse, particularly childhood abuse. They had significantly higher scores on the Addiction Severity Index, were more likely to have comorbid affective disorder, and less likely to comply with aftercare. These results suggest that screening for victimization and PTSD among women presenting for substance abuse treatment may have important prognostic and treatment implications.

Cocaine Dependence with and without Post-traumatic Stress Disorder: A Comparison of Substance Use, Trauma History and Psychiatric Comorbidity

This study examined the relationship between substance use, trauma history, post-traumatic stress disorder (PTSD), and psychiatric comorbidity in a treatment seeking sample of cocaine dependent individuals (N = 91). Structured clinical interviews revealed that 42.9% of the sample met DSM-III-R criteria for lifetime PTSD. Comparisons between individuals with and without lifetime PTSD revealed that individuals with PTSD had significantly higher rates of exposure to traumatic events, earlier age of first assault, more severe symptomatology, and higher rates of Axis I and Axis II diagnoses. The results illustrate a high incidence of PTSD among cocaine dependent individuals. Routine assessment of trauma history and PTSD may assist in the identification of a subgroup of cocaine users in need of special prevention and treatment efforts.

Screening for PTSD in a substance abuse sample: Psychometric properties of a modified version of the PTSD symptom scale self-report

The high rate of posttraumatic stress disorder (PTSD) among substance use disorder (SUD) patients has been documented in research protocols, but there is evidence that it is markedly under-diagnosed in clinical settings. To address the need for a brief self-report measure to identify SUD patients who may benefit from further assessment and/or treatment for PTSD, the psychometric properties of a modified version of the PTSD Symptom Scale Self-Report (PSSSR) were examined in a treatment-seeking SUD sample (N = 118). The modified version of the PSS-SR, which measures both frequency and severity of PTSD symptoms, demonstrated good internal consistency reliability and was correlated with other self-report measures of trauma-related symptomatology. Comparisons between a structured PTSD diagnostic interview and the modified PSS-SR indicated that 89% of the PTSD positive patients were correctly classified by the modified PSS-SR. The clinical relevance of these findings was discussed.

Comorbidity of bulimia nervosa and alcohol use disorders: results from the National Women's Study.

OBJECTIVE The nature of the relationship between bulimia nervosa (BN) and alcohol abuse/alcohol dependence (AA/AD) and the extent to which women with BN+AA differ from women with BN-AA were examined in a national sample of women (N = 3,006). METHOD The sample of was generated by multistage geographic sampling and interviews were conducted by telephone. RESULTS AA was higher in women with BN compared to women without BN or binge eating disorder, only when the influence of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) was controlled. Prevalence rates of AA and AD were similar in women with BN, MDD, and PTSD. Analyses indicated that the relationship between BN and AA/AD may be indirect and influenced by associations with MDD and PTSD. Women with BN+AA did not differ from those with BN-AA on most variables concerning victimization, family of origin, and disordered eating. DISCUSSION Evaluation of MDD and PTSD in women presenting for treatment of BN and/or alcohol use disorders (AUDs) is recommended.

Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: description of procedures

An estimated 30% to 50% of cocaine-dependent individuals meet criteria for lifetime PTSD. This comorbidity has detrimental effects on clinical presentation, and treatment course and outcome. Cocaine dependence is associated with increased rates of exposure to trauma, more severe symptoms, higher rates of treatment attrition and retraumatization, and greater vulnerability to PTSD when compared to other substance use disorders. These associations underscore the need for effective treatments that address issues particular to PTSD in a manner tolerable to cocaine-dependent individuals. This article describes a manualized psychotherapy developed specifically for individuals with PTSD and cocaine dependence. Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD) provides coping skills training, cognitive restructuring techniques, and relapse prevention strategies to reduce cocaine use. In-vivo and imaginal exposure therapy techniques are incorporated to reduce PTSD symptom severity. Primary treatment goals include psychoeducation specific to the interrelationship between PTSD and cocaine dependence, and clinically meaningful reductions in cocaine use and PTSD symptomatology. Secondary goals include a reduction in HIV high-risk behaviors and improved functioning in associated areas, such as anger and negative affect management.