Lisa M. Najavits

The Link Between Substance Abuse and Posttraumatic Stress Disorder in Women: A Research Review

Research has documented a high incidence of comorbid post-traumatic stress disorder (PTSD) and substance abuse. Women substance abusers, in particular, show high rates of this dual diagnosis (30% to 59%), most commonly deriving from a history of repetitive childhood physical and/or sexual assault. Rates for men are two to three times lower and typically stem from combat or crime trauma. Patients with both disorders are characterized by high severity on a multitude of psychological and treatment variables and use of the most severe drugs (cocaine and opioids). Treatment research on women is limited but suggests the possibility of retaining patients and achieving positive outcomes.

A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: findings from a pilot study

Treatment for comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD) is of particular relevance for incarcerated women, whose rates of PTSD and SUD are considerably higher than women in the general population. Yet virtually no treatments have been developed or systematically evaluated that target concurrently the symptoms of PTSD and SUD in this underserved population. This preliminary study evaluates the initial efficacy of a cognitive-behavioral treatment, Seeking Safety, as an adjunct to treatment-as-usual in an uncontrolled pilot study of incarcerated women with current SUD and comorbid PTSD. Of the 17 incarcerated women with PTSD and SUD who received Seeking Safety treatment and had outcome data, results show that nine (53%) no longer met criteria for PTSD at the end of treatment; at a followup 3 months later, seven (46%) still no longer met criteria for PTSD. Additionally, there was a significant decrease in PTSD symptoms from intake to posttreatment, which was maintained at the 3-month followup assessment. Based on results from a diagnostic interview and results of urinalyses, six (35%) of the women reported the use of illegal substances within 3 months from release from prison. Measures of client satisfaction with treatment were high. Recidivism rate (return to prison) was 33% at a 3-month followup. Overall, our data suggest that Seeking Safety treatment appears to be appealing to incarcerated women with SUD and PTSD and that the treatment has the potential to be beneficial, especially for improving PTSD symptoms. However, these findings are tentative given that there was no control group.

A Randomized Trial of Integrated Group Therapy Versus Group Drug Counseling for Patients With Bipolar Disorder and Substance Dependence

OBJECTIVE Although bipolar disorder and substance use disorder frequently co-occur, there is little information on the effectiveness of behavioral treatment for this population. Integrated group therapy, which addresses the two disorders simultaneously, was compared with group drug counseling, which focuses on substance use. The authors hypothesized that patients receiving integrated group therapy would have fewer days of substance use and fewer weeks ill with bipolar disorder. METHOD A randomized controlled trial compared 20 weeks of integrated group therapy or group drug counseling with 3 months of posttreatment follow-up. Sixty-two patients with bipolar disorder and current substance dependence, treated with mood stabilizers for >or=2 weeks, were randomly assigned to integrated group therapy (N=31) or group drug counseling (N=31). The primary outcome measure was the number of days of substance use. The primary mood outcome was the number of weeks ill with a mood episode. RESULTS Intention-to-treat analysis revealed significantly fewer days of substance use for integrated group therapy patients during treatment and follow-up. Groups were similar in the number of weeks ill with bipolar disorder during treatment and follow-up, although integrated group therapy patients had more depressive and manic symptoms. CONCLUSIONS Integrated group therapy, a new treatment developed specifically for patients with bipolar disorder and substance dependence, appears to be a promising approach to reduce substance use in this population.

Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD.

This randomized controlled pilot study compared a cognitive-behavioral therapy (Seeking Safety; SS) plus treatment-as-usual (TAU) to TAU-alone in 49 incarcerated women with substance use disorder (SUD) and posttraumatic stress disorder (PTSD; full or subthreshold). Seeking Safety consisted of a voluntary group treatment during incarceration and individual treatment after prison release. TAU was required in the prison and comprised 180 to 240 hours of individual and group treatment over 6 to 8 weeks. Assessments occurred at intake, 12 weeks after intake, and 3 and 6 months after release from prison. There were no significant differences between conditions on all key domains (PTSD, SUD, psychopathology, and legal problems); but both conditions showed significant improvements from intake to later time points on all of these outcomes across time. Secondary analyses at follow-up found trends for SS participants improving on clinician-rated PTSD symptoms and TAU participants worsening on self-reported PTSD symptoms. Also, SS demonstrated continued improvement on psychopathology at 3 and 6 months, whereas TAU did not. However, alcohol use improved more for TAU during follow-up. Satisfaction with SS was high, and a greater number of SS sessions was associated with greater improvement on PTSD and drug use. Six months after release from prison, 53% of the women in both conditions reported a remission in PTSD. Study limitations include lack of assessment of SS outcomes at end of group treatment; lack of blind assessment; omission of the SS case management component; and possible contamination between the two conditions. The complex needs of this population are discussed.

Group cognitive-behavioral therapy for women with PTSD and substance use disorder.

This paper describes a model of group cognitive-behavioral therapy (CBT) for women with posttraumatic stress disorder (PTSD) and substance use disorder (SUD). The need for specialized treatment derives from the high incidence of these comorbid disorders among women as well as from their particular clinical presentation and treatment needs. The treatment educates patients about the two disorders, promotes self-control skills to manage overwhelming affects, teaches functional behaviors that may have deteriorated as a result of the disorders, and provides relapse prevention training. The program draws on educational principles to make it accessible for this population: visual aids, education for the patient role, teaching for generalization, emphasis on structured treatment, testing of acquired knowledge of CBT, affectively engaging themes and materials, and memory enhancement devices.

Seeking Safety Plus Exposure Therapy: An Outcome Study on Dual Diagnosis Men

Abstract This study arose out of a prominent clinical need: effective treatment for comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) in civilian men. This dual diagnosis is estimated to occur in up to 38% of men in substance abuse treatment, and generally portends a more severe clinical course than SUD alone. Clinical issues include self-harm, suicidality, perpetration of violence against others, and HIV risk behaviors. This study appears to be the first outcome trial to address a sample of civilian men with PTSD and SUD using manualized psychosocial treatment. It evaluates a novel combination treatment, Seeking Safety plus Exposure Therapy-Revised. The former is a coping skills treatment designed for PTSD and SUD; the latter is an adaptation of Foas exposure therapy, modified for PTSD and SUD. In this small sample (n = 5) outpatient pilot trial, patients with current PTSD and current SUD were offered 30 sessions over five months, with the option to select how much of each type of treatment they preferred. Outcome results showed significant improvements in drug use; family/social functioning; trauma symptoms; anxiety; dissociation; sexuality; hostility; overall functioning; meaningfulness; and feelings and thoughts related to safety. Trends indicating improvement on 11 other outcome variables were also found. Treatment attendance, satisfaction, and alliance were extremely high. The need for further evaluation using more rigorous methodology is discussed.

Clinical challenges in the treatment of patients with posttraumatic stress disorder and substance abuse.

Purpose of review The aim of this article is to review the current literature on co-occuring posttraumatic stress disorder and substance-use disorder, with an emphasis on clinical aspects and emerging treatments. Recent findings In clinical populations (focusing on either disorder), about 25–50% have a lifetime dual diagnosis of posttraumatic stress disorder and substance-use disorder. Patients with both disorders have a more severe clinical profile than those with either disorder alone, lower functioning, poorer well being, and worse outcomes across a variety of measures. In recent years, several promising treatment programs have been developed specifically for co-occuring posttraumatic stress disorder and substance-use disorder, with one model having been established as effective thus far. Summary Comorbid posttraumatic stress disorder/substance-use disorder is a frequent diagnosis in clinical populations that severely affects course and outcome. Treatment approaches appropriate for this vulnerable population need to be evaluated further and implemented in routine practice.

Self-Harm and Suicidal Behavior in Women with Comorbid PTSD and Substance Dependence

This study examined the frequency, methods, and correlates of self-harm and suicidal behavior in 65 outpatient women with comorbid posttraumatic stress disorder (PTSD) and substance dependence (SD). Results showed high rates of suicide attempts, self-harm, suicidal ideation, and self-harm ideation for the prior three months. The most common methods were overdosing and cutting/scratching. Both PTSD and SD were perceived as contributing to self-harm and suicidal behavior. Women who had and had not engaged in such behavior differed in SD diagnoses and reasons for staying safe, but not in the number or type of traumatic experiences, age at first trauma, or substance abuse diagnoses.

Early Prediction of Initiation of Abstinence from Cocaine: Use of a Craving Questionnaire

The authors administered a five-item craving questionnaire daily to 86 outpatients to determine whether initial craving scores predicted the likelihood of initiation of abstinence within a 30-day period. Patients with higher mean craving scores during the first 3 days of the study were less likely to initiate abstinence. However the relationship between craving and abstinence initiation was not linear. Rather, patients in the top quartile of craving scores were significantly less likely to abstain than were patients in the lower three quartiles. The findings suggest that this rapid, easily administered craving questionnaire may have short-term predictive validity.

Psychotherapists' views of treatment manuals.

How helpful are treatment manuals to practicing psychotherapists? A survey of 47 cognitive-behavioral therapists explored their overall responses to manuals (e.g., number read, favorite manuals) and their descriptions of the ideal manual (ratings of 20 features). Findings indicated a very positive view of manuals, extensive use, and few concerns. Ratings of the ideal manual emphasized practical advice, the notion that more is better, and endorsement of some features that are typically not included (e.g., illustrations). Implications for practice are discussed, including ways that therapists can make the best use of manuals and awareness of limitations of manuals for mastering a treatment.