Abstract
Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are prevalent and frequently co-occur. Comorbid PTSD/SUD is associated with a more complex and costly clinical course when compared with either disorder alone, including increased chronic physical health problems, poorer social functioning, higher rates of suicide attempts, more legal problems, increased risk of violence, worse treatment adherence, and less improvement during treatment. In response, psychosocial treatment options have increased substantially over the past decade and integrated approaches – treatments that address symptoms of both PTSD and SUD concurrently –are fast becoming the preferred model for treatment. This paper reviews the prevalence, etiology and assessment practices as well as advances in the behavioral and pharmacologic treatment of comorbid PTSD and SUDs.
Keywords: PTSD, posttraumatic stress disorder, trauma, substance use disorders, addiction, integrated treatment
Overview of PTSD and Substance Use Disorders
Posttraumatic stress disorder (PTSD) is an anxiety disorder that may develop subsequent to exposure to a traumatic event (experienced or witnessed). Traumatic events are defined as events that involve actual or threatened death, serious injury, or threat to the physical integrity of oneself or others, and are responded to with intense fear, helplessness or horror (American Psychiatric Association, 2000). Diagnosis of PTSD requires that the traumatic event (Criterion A) is followed by at least one month of the following three distinct symptom clusters; intrusive recollection or reexperiencing (Criterion B), avoidance or emotional numbing (Criterion C), and hyperarousal (Criterion D). With respect to substance use disorders (SUDs), the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) provides diagnostic criteria for two forms of SUDs – substance abuse and substance dependence. Substance abuse is characterized by a maladaptive pattern of use leading to clinically significant impairment or distress. Maladaptive use is described as the recurrence of at least one of the following: use in physically hazardous situations, substance-related legal problems, failure to fulfill major role obligations, or social/interpersonal problems related to use. Substance dependence is also a maladaptive pattern of use that is characterized by three or more of the following: (1) tolerance of the substance; (2) withdrawal symptoms when the substance is reduced or ceased; (3) using more than was planned or for a longer period than was planned; (4) unsuccessful efforts to reduce or control use; (5) significant time spent obtaining, using, or recovering from use; (6) interference with important social, occupational, or recreational activities; and (7) continued use despite knowledge of its cause or exacerbation of a physical or psychological problem(s).
Comorbidity of PTSD and SUDs is prevalent across a diverse range of populations and settings. In addition, comorbid PTSD/SUD is associated with a more complex and costly clinical course when compared with either disorder alone, including increased chronic physical health problems, poorer social functioning, higher rates of suicide attempts, more legal problems, increased risk of violence, worse treatment adherence, and less improvement during treatment (Back et al., 2000; Driessen et al., 2008; Norman, Tate, Anderson, & Brown, 2007; Ouimette, Brown, & Najavits, 1998; Ouimette, Goodwin, & Brown, 2006; Tarrier, 2004; Tate, Norman, McQuiad, & Brown, 2007; Young, Rosen, & Finney, 2005). The current paper (1) reviews the epidemiology and etiology of comorbid PTSD/SUD; (2) highlights commonly used self-report, clinician-administered, and biological assessments for PTSD and SUDs; and (3) discusses advances in evidence-based psychotherapeutic and pharmacologic treatment options for patients presenting with comorbid PTSD/SUD.
Epidemiology and Etiology of PTSD and SUDs
Several large-scale epidemiological surveys conducted among the general population over the past two decades have demonstrated the high co-occurrence of PTSD and SUDs. The National Comorbidity Survey (NCS; N = 5,877), which assessed the prevalence and co-occurrence of a range of psychiatric disorders using the Diagnostic and Statistical Manual, Third Edition-Revised (DSM-III-R) revised diagnostic criteria, provided one of the earliest national estimates of the scope of the problem among the general U.S. population (Kessler, Sonega, Bromet, Hughes, & Neslon, 1995). NCS data indicated a 7.8% lifetime prevalence of PTSD and a 26.6% lifetime prevalence of SUDs; individuals with PTSD were 2 to 4 times more likely than individuals without PTSD to meet criteria for an SUD. The National Comorbidity Survey – Replication (N = 9,282; Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005) conducted approximately ten years later using DSM-IV diagnostic criteria (American Psychiatric Association, 2000), documented similar estimates of lifetime PTSD (6.4%) and lifetime SUDs (35.3%). More recently, data from the 2010 National Epidemiologic Survey on Alcohol and Related Conditions (N = 34,653) estimated a lifetime PTSD prevalence of 6.4% (Pietrzak, Goldstein, Southwick, & Grant, 2011). Among individuals with PTSD, nearly half (46.4%) also met criteria for an SUD and more than one-in-five (22.3%) met criteria for substance dependence. Similarly, international data from the Australian National Survey of Mental Health and Well-Being (N = 10,641) found that over one-third (34.4%) of individuals meeting criteria for PTSD also met criteria for at least one SUD, most commonly alcohol use disorders (Mills, Teeson, Ross, Peters, 2006).
Among treatment-seeking populations, high rates of comorbid PTSD and SUDs also have been consistently observed. Patients with PTSD have been shown to be up to 14 times more likely than patients without PTSD to have an SUD (Chilcoat & Menard, 2003; Ford, Russo, & Mallon, 2007). Conversely, among patients seeking treatment for SUDs, lifetime PTSD rates range between 30% and over 60% (Back et al., 2000; Brady, Back, & Coffey, 2004; Dansky, Brady, & Roberts, 1994; Jacobsen, Southwick, & Kosten, 2001; Stewart, Conrod, Samoluk, Pihl, Dongier, 2000; Triffleman, Marmar, Delucchi, & Ronfeldt, 1995). The variation in estimates observed across the aforementioned studies is likely attributable to differences in the types of clinics sampled, variant patient populations and measurement techniques employed.
Finally, research on Veteran populations demonstrates that, in comparison to the general population, Veterans are at increased risk for developing both PTSD and SUDs, and that severity of combat exposure is directly linked to risk for development and chronicity of PTSD symptoms (Hoge et al., 2004; Kang, Natelson, Mahan, Lee, & Murphy, 2003). A recent study assessed army Veterans three to four months post-deployment from Iraq and found a 27% prevalence rate for alcohol misuse, as well as a significant association between severity of combat exposure and alcohol misuse, such that those with higher severity of combat exposure had a 93% higher odds of screening positive for alcohol misuse (Santiago et al., 2010). Prevalence rates for SUDs among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans have been estimated at 21%, and approximately 15% to 20% of OEF/OIF military troops meet criteria for PTSD post-deployment (Bray & Houranni, 2007; Hoge, et al., 2004; Seal, Berthenhal, Miner, Sen, & Marmar, 2007; Thomas et al., 2010). Research also documents high rates of comorbid PTSD/SUD among Veterans (Centers for Disease Control and Prevention, 1988; Shipherd, Stafford, & Tanner, 2005). A recent study (Petrakis, Rosenheck, & Desai, 2011) using national administrative data from the Department of Veterans Affairs indicated that, among Veterans who had served in Vietnam era or later, almost half (41.4%) with an SUD were dually diagnosed with PTSD.
Etiology and Order of Onset
Several theories have been posited to explain the functional association between PTSD and SUDs. The self-medication theory (Khantzian, 1985, 1990, 1997; Reed, Anthony, & Breslau, 2007), perhaps the most prominent theory, postulates that substance use serves as an attempt to alleviate PTSD symptoms. In support of this theory, one study (Saladin, Brady, Dansky, & Kilpatrick, 1995) found that hyperarousal and avoidance symptoms were more prominent among individuals with comorbid PTSD/SUD, as compared to those with PTSD alone. Further, among individauls with comorbid PTSD/SUD, alcohol dependence was more strongly associated with hyperarousal cluster (Criterion D) symptoms than cocaine dependence. Therefore, an individual’s drug of choice, either central nervous system depressant or stimulant, in comorbid PTSD/SUD cases may reflect an attempt to alleviate a particular cluster of symptoms. Experimental findings among individuals with comorbid PTSD/SUD demonstrate a consistent increase in substance craving in response to presentation of personalized trauma cues (Coffey et al., 2002). Furthermore, increase in craving is predicted by severity of PTSD symptoms (Saladin et al., 2003), and trauma-cue elicited craving is reduced following trauma-focused imaginal exposure (Coffey, Stasiewicz, Hughes, & Brimo, 2006). Adding to this complex relationship, withdrawal from substances may closely mimic some symptoms of PTSD (e.g., sleep disturbance, difficulty concentrating, feelings of detachment, irritability) and contribute to a reinforcing cycle of self-medication that fosters the development of an SUD. Although the direction of the causal relationship between comorbid PTSD and SUDs is likely to vary from one individual to another, in the majority of cases the development of PTSD precedes the development of the SUD, providing temporal support for the self-medication hypothesis (Back, Brady, Sonne, & Verduin, 2006; Back, Jackson, Sonne, & Brady, 2005; Chilcoat & Breslau, 1998; Compton, Cottler, Phelps, Abdallah, & Sptiznagel, 2000; Jacobsen, Southwick, & Kosten, 2001; Stewart & Conrod, 2003). More recently, Ouimette and colleagues (2010) followed 35 outpatients with comorbid PTSD and SUDs and tracked weekly fluctuations in symptoms over a 26-week period in order to examine dynamic interactions between symptoms of PTSD and SUDs. Overall, the findings support the self-medication hypothesis and suggest that PTSD and SUD symptoms co-vary concurrently and over time, such that increases in PTSD symptoms are associated with increases in symptoms of substance dependence. Several studies investigating patients’ perceptions of the interrelationship of their PTSD and SUD symptoms also provide support for the self-medication hypothesis (Back, Brady, Jaanimagi & Jackson, 2006; Brown, Stout, & Gannon-Rowley, 1989).
Alternatively, competing theories hypothesize that SUDs precede and increase risk of the development of PTSD. Assuming this order of onset, the probability of developing PTSD is increased via two potential causal pathways. First, the high-risk hypothesis (Chilcoat & Breslau, 1998; Acierno, Resnick, Kilpatrick, Saunders, & Best, 1999) posits that the lifestyle of a substance abuser, which typically involves significant time spent in dangerous environments or engaging in high-risk behaviors associated with obtaining or using alcohol or drugs, may increase the likelihood of experiencing a traumatic event and subsequently developing PTSD. Second, the susceptibility hypothesis proposes that the increased anxiety and arousal that often accompanies chronic substance abuse, in addition to poor coping skills, may increase biologic vulnerability to developing PTSD subsequent to trauma exposure (Jacobsen, Southwick, & Kosten, 2001; Sharkansky, Brief, Peirce, Meehan, & Mannix, 1999; Stewart, Conrod, Samoluk, Pihl, & Dongier, 2000). Lastly, although not a leading theoretical perspective, there is some evidence that other common factors may play a role in the development of comorbid PTSD and SUD. Plausible factors that have been investigated include genetics, common neurophysiologic systems, and prior exposure to traumatic events (Norman et al., 2012; Khoury, Tang, Bradley, Cubells, & Ressler, 2010; Kingston & Raghavan, 2009; Stewart & Conrod, 2008).
In summary, the comorbidity of PTSD and SUDs is striking, particularly among treatment seeking and military populations. The mechanisms underlying the interplay between PTSD and SUD symptoms are multifaceted and complex. Whereas the majority of research supports the primacy of PTSD with respect to order of onset, empirical evidence also exists to lend support to an array of etiological theories. Finally, the comorbid presentation of PTSD and SUDs is associated with a more severe clinical presentation and poorer treatment prognosis. Given the frequent co-occurrence of PTSD and SUDs, and the negative impact of this comorbidity on treatment outcome, much recent attention has been given to the development and evaluation of improved assessment and treatment options. These are discussed in the following sections.
Assessment of Comorbid PTSD and SUD
The thorough assessment of symptoms is an essential component in the effective treatment of comorbid PTSD and SUDs. The primary goals of the assessment include the detection of trauma exposure and problematic substance use behaviors, evaluation of DSM PTSD and SUD diagnoses, and ongoing assessment of symptom severity during treatment (Steenkamp, McLean, Arditte, & Litz, 2011; Tucker, Murphy, & Kertesz, 2011). Assessment procedures may involve several steps, ranging from the initial screening typically conducted in non-specialty clinics to lengthy diagnostic interviews, self-report monitoring forms and symptom questionnaires, and biological tests (Tucker et al., 2011). Together, the information gathered through these various assessments provides invaluable information to inform treatment planning and monitor progress. Numerous assessment tools have been developed and investigated for PTSD and SUDs, many of which are beyond the scope of this review. Thus, the following sections on assessment focus on the most common and empirically-supported measures relevant to diagnostics, treatment planning, and treatment monitoring for comorbid PTSD and SUDs. Assessment tools are summarized in Table 1.
Table 1.
Measure | Purpose | Admin Time (Appx. Mins.) | Source Reference |
---|---|---|---|
Screening Measures | |||
Trauma Life Events Questionnaire | Trauma/PTSD Screening | 10–15 | Kubany et al., 2000 |
Primary Care – PTSD Screen (PC-PTSD) | PTSD Screening | 1–2 | Prins et al., 2003 |
Short Form of the PTSD Checklist – Civilian Version | PTSD Screening | 1–2 | Lang & Stein, 2005 |
Short Posttraumatic Stress Disorder Rating Interview (SPRINT) | PTSD Screening | 2–3 | Connor & Davidson, 2001 |
Trauma Screening Questionnaire (TSQ) | PTSD Screening | 2–3 | Brewin et al., 2002 |
Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) | SUD Screening | 7–10 | Humeniuk et al., 2008 |
Alcohol Use Disorders Identification Test (AUDIT) | SUD Screening | 2–3 | Saunders et al., 1993 |
CAGE | SUD Screening | < 1 | Cooney et al., 1995 |
Drug Abuse Screening Test (DAST) | SUD Screening | 5 | Gavin et al., 1989 |
Drug Use Disorders Identification Test (DUDIT) | SUD Screening | 5–10 | Berman et al., 2005 |
Diagnostic Measures | |||
Clinician Administered PTSD Scale (CAPS) | PTSD Diagnosis | 45–60 | Blake et al., 1995 |
Alcohol Use Disorders and Associated Disabilities Interview Schedule | DSM Diagnosis | 60 | Grant & Hasin, 1990 |
Anxiety Disorder Interview Schedule for DSM-IV (ADIS) | DSM Diagnosis | ≤ 120 | DiNardo et al., 1994 |
Composite International Diagnostic Interview, version 2 (CIDI-2) | DSM and ICD-10 Diagnosis | ≤ 75 | Robins et al., 1989 |
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) | DSM Diagnosis | Varies Based on Modules Delivered | First et al., 1996 |
Mini International Neuropsychiatric Interview (MINI) | DSM Diagnosis | 15 | Sheehan et al., 1998 |
Treatment Planning Measures | |||
Drinking Motives Questionnaire (DMQ) | Motives for Use | 5–10 | Cooper, 1994 |
Inventory of Drinking Situations | Motives for Use | 15–20 | Annis, 1982 |
Inventory of Drug Taking Situations (IDTS) | Motives for Use | 10 | Annis & Martin, 1985 |
Marijuana Motives Questionnaire | Motives for Use | 5–10 | Simons et al., 1998 |
Reasons for Drinking Questionnaire | Motives for Use | 5 | Zwyiak et al., 1996 |
Symptom Tracking Measures | |||
Impact of Events Scale-Revised (IES-R) | PTSD Symptom Severity | 5–10 | Weiss & Marmar, 1996 |
PTSD Checklist (PCL) | PTSD Symptom Severity | 5 | Blanchard et al., 1996 |
PTSD Symptom Scale (PDS) | PTSD Symptom Severity | 20 | Foa et al., 1993 |
Purdue PTSD Scale-Revised | PTSD Symptom Severity | 10–15 | Lauterbach & Vrana, 1996 |
Addiction Severity Index (ASI) | SUD and Associated Symptom Severity | 50–60 | McLellean et al., 1992 |
Alcohol Dependence Scale | SUD Symptom Severity | 5 | Skinner & Horn, 1984 |
Drinker Inventory of Consequences | SUD Symptom Severity | 10–15 | Miller et al., 1995 |
Timeline Followback (TLFB) | SUD Symptom Frequency and Severity | ≤ 30 | Sobell & Sobell, 1995 |
Initial Screening
Several brief tools have been developed to screen for exposure to a DSM Criterion A traumatic event and problematic substance use behaviors in order to permit rapid identification of persons at-risk for PTSD and SUDs. These screening tools are especially relevant to settings that necessitate that a large amount of data be collected in a short period of time, such as in primary care clinics (Bufka & Camp, 2011). Although there is no standard trauma-exposure screener (Steenkamp et al., 2011) several options with growing support in the literature exist (Gray, Elhai, Owen, & Monroe, 2009; Kubany et al., 2000). Potential screeners with psychometric support include the Trauma Assessment of Adults (Gray et al., 2009), Life Events Checklist (Gray, Litz, Hsu, & Lombardo, 2004), and the Trauma Life Events Questionnaire (Kubany et al., 2000). In addition to trauma exposure screeners, PTSD symptom screeners frequently used to indicate the need for further structured assessment include the Primary Care PTSD Screen (PC-PTSD; Prins et al., 2003), the Short Form of the PTSD Checklist-Civilian Version (Lang & Stein, 2005), Trauma Screening Questionnaire (TSQ; Brewin et al, 2002), and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT; Connor & Davidson, 2001).
Screening measures for SUDs have been studied extensively and are far more commonly used (Tucker et al., 2011). Popular alcohol screening measures include the Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993), CAGE Questionnaire (Cooney, Zweben & Fleming, 1995), and the Michigan Alcoholism Screening Test (MAST; Selzer, 1971). In addition, parallel versions of these screening measures have been developed for drug abuse: the Drug Use Disorder Identification Test (DUDIT; Berman, Bergman, Palmsteirna, & Schlyter, 2005) and the Drug Abuse Screening Test (DAST; Gavin, Ross, & Skinner, 1989). The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST; Humeniuk et al., 2008), developed by the World Health Organization, is recommended by the National Institute on Drug Abuse as a comprehensive screener to aid primary health care professionals in the detection and management of a range of SUDs and related problems.
Biological tests for alcohol and drug use (e.g., breathalyzer test, blood tests, and urinalysis) are another set of useful screening procedures due to the ease of data collection in medical settings. Patients that screen positive should be referred to specialty services. Several biological assessment options exist for use as either adjunctive or alternative assessments of SUD. Urine drug screening, or urinalysis, is perhaps the most common and preferred method for detecting illicit drug use (Richter & Johnson, 2001; Wolff, Welch, & Strang, 1999). Urinalysis is cost-effective, minimally-invasive, and quantitative systems exist for measuring the pattern, frequency, and amount of use (e.g., Preston, Silverman, Schuster, & Cone, 1997). Urinalysis is one of the most longstanding biological assessments of use and, as such, many of its drawbacks have been identified and, in some cases, addressed. Limitations include its relatively narrow window of detection (usually 3 days or less for most substances), easy alteration with chemicals or clean urine samples, and susceptibility to false positives (Jaffe, 1998; Widdop & Caldwell, 1991).
Although urinalysis is the predominant and often preferred biological method of assessment, SUD screening may also involve testing other bodily fluids, such as blood and saliva (Wolff et al., 1999). These methods of testing are less often used due to higher cost of administration, increased invasiveness, and narrow detection windows; however, percent carbohydrate-deficient transferrin (CDT), a blood-based testing method, is increasingly considered one of the preferred modes of assessing for chronic heavy alcohol use (Arndt, 2001). CDT testing is particularly useful when used in combination with other indicators such as liver enzymes (Aithal et al., 1998). Finally, hair analysis techniques also exist, but are less often used in isolation due to numerous identified biases and limitations (Wolff et al., 1999).
Diagnosis
After initial screening, more advanced assessment procedures should be conducted to establish clinical diagnosis of PTSD and SUDs based on DSM-IV diagnostic criteria. In general, these diagnostic assessments can take several hours to complete and require significant training to administer. Although excellent disorder-specific interviews exist for both PTSD (Clinician Administered PTSD Scale; Blake et al., 1995) and SUDs (Alcohol Use Disorders and Associated Disabilities Interview Schedule; Grant & Hasin, 1990), general psychiatric diagnostic interviews that assess the DSM Axis I mental disorders may be better suited for assessing for comorbidity. One of the best examples of this is the Structured Clinical Interview of DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1996). The SCID has been shown to provide valid and reliable diagnostics for PTSD and SUDs as well as most other Axis I disorders. Other semi-structured interviews include the Anxiety Disorder Interview Schedule for DSM-IV (Di Nardo, Brown, & Barlow, 1994), which provides a more thorough assessment of disorders and symptom severity, the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998), which also provides the DSM diagnoses but takes approximately half the time to administer as the same modules of the SCID, and the Composite International Diagnostic Interview version 2 (CIDI-2; Robins et al., 1989), which includes modules assessing all major diagnostic disorders and serving the criteria of both the DSM-IV and the ICD-10.
Symptom Severity and Treatment Tracking
Once the PTSD/SUD diagnoses have been assessed, symptom frequency and severity are the next essential components to treatment planning and monitoring. A large number of measures have been developed for monitoring PTSD and SUDs symptoms. These measures are largely brief, self-report assessments of a wide range of symptoms associated with each of the disorders, and with strong psychometric properties. In PTSD, these measures are fairly straight-forward in that they generally assess symptom severity of the 17 symptoms of PTSD, as defined by the DSM. Popular examples of these include the PTSD Checklist (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996), PTSD Symptom Scale (Foa, Riggs, Dancu, & Rothbaum, 1993), Impact of Events Scale-Revised (Weiss & Marmar, 1996), and the Purdue PTSD Scale –Revised (Lauterbach & Vrana, 1996). These measures provide quick feedback regarding symptom severity, are sensitive to changes that occur during treatment, and include cutoff scores to inform diagnostic status (Steenkamp et al., 2011). Separate trauma-specific versions of the various measures also have been developed (e.g., military vs. civilian; Steenkamp et al., 2011).
The assessment of SUDs involves the monitoring of substance use behaviors (frequency and intensity of use) and biological markers of use (Tucker et al., 2011). The Timeline Followback (TLFB; Sobell & Sobell, 1995) is a popular monitoring form that uses a calendar to record estimates of daily drinking or other drug use over long periods of time. The TLFB has been used to monitor changes in substance use during the course of treatment (Back et al., 2005; Back et al., 2006; Back, Killeen, Foa, Santa Ana, Gros, & Brady, 2012; Brady, Dansky, Back, Foa, & Carroll, 2001; Brady, Sonne, Anton, Randall, Back,& Simpson, 2005). Additional measures should be completed to assess the severity of use behaviors and consequences on health and psychosocial functioning, including the Alcohol Dependence Scale (Skinner & Horn, 1984), Drinker Inventory of Consequences (Miller, Tonigan, & Longabaugh, 1995), and the Addiction Severity Index (McLellan et al., 1992). These measures have been found to be useful across different levels of SUD severity and can be informative in treatment planning, especially in regards to motivational interventions (Tucker et al., 2011).
Special Considerations for Comorbidity
Due to the high comorbidity and complexity of PTSD and SUDs, additional assessments should be considered that may provide greater information about the relationship between symptoms. For example, several measures have been developed that assess the motivation for alcohol and drug use behaviors, such as the Inventory of Drinking Situations (Annis, 1982), Inventory of Drug Taking Situations (Annis & Martin, 1985; Annis et al., 1997), Drinking Motives Questionnaire (Cooper, 1994; Grant, Stewart, O’Connor, Blackwell, & Conrod, 2007), Reasons for Drinking Questionnaire (Zywiak, Connors, Masito, & Westerberg, 1996) and Marijuana Motives Questionnaire (Simons et al., 1998). These measures are all self-report and ask individuals to indicate situations or circumstances during which they are most likely to use substances. For examples, the Inventory of Drinking Situations generates information regarding three global categories and eight subcategories of drinking situations: 1) negative situations (Unpleasant Emotions, Physical Discomfort, Conflict with Others), 2) positive situations (Pleasant Emotions, Pleasant Times with Others), and 3) temptation situations (Social Pressure, Urges/Temptations, Testing Personal Control). Similar subscales for coping with substances have been included in newer measures in the anxiety literature as well (Gros, Simms, Antony, & McCabe, 2012); however, these measures are not specifically for PTSD symptomatology. Self-monitoring and biological tests should be completed throughout treatment to sufficiently monitor treatment response.
The Evolution of Integrated Behavioral Treatments
Both psychosocial and pharmacologic interventions are important for the treatment of comorbid PTSD and SUDs. Historically, the standard of care has been to treat the SUD first and defer treatment of trauma/PTSD (Nace, 1988; Schnitt & Nocks, 1984), despite growing evidence that: (1) trauma exposure is commonplace among SUD populations (Najavits et al., 2003; Wasserman, Havassy, & Boles, 1997); (2) over half of SUD patients also suffer from PTSD (Cottler, Compton, Mager, Spitznagel, & Janca, 1992; Jacobsen et al., 2001; Mills et al., 2006); (3) symptoms of SUDs co-vary concurrently with those of PTSD (Ouimette et al., 2010); and (4) patients perceive an interrelation between their PTSD and SUD symptoms (Back et al., 2006; Brown, Stout, Gannon-Rowley, 1998). In this model, known as the sequential model of treatment, the SUD is treated first and trauma-focused work is deferred until a period of sustained abstinence (e.g., 3–6 months) has been achieved. If the patient follows up on trauma/PTSD treatment subsequent to completion of treatment for their SUD, it is usually provided by a different clinician at a separate treatment clinic. Proponents of the sequential model state that continued substance use during therapy will impede therapeutic efforts and/or that PTSD treatment may induce relapse (Nace, 1988; Pitman et al., 1991) and there is some evidence to suggest that PTSD symptoms can be reduced as a function of acute and protracted abstinence attained via SUD treatment (Coffey, Schumacher, Brady, & Cotton, 2007). Proponents of this model operate under Pandora’s Box hypothesis, which states that efforts to address PTSD symptoms during the early stages of SUD treatment will result in an increase in negative affect and hyperarousal symptoms, with which the patient will be ill-equipped to cope and therefore more likely to relapse (Souza & Spates, 2008). However, there is little empirical data to support these concerns, and there is scant evidence to support the efficacy of the sequential model singularly or in comparison to other treatment models. Furthermore, only a minority of PTSD/SUD patients (under 30%) indicate a preference for the sequential model (Back, Brady, Jaanimagi, & Jackson, 2006; Brown et al., 1998).
In contrast, the integrated model of treatment acknowledges the notable interplay between symptoms of PTSD and SUDs and, in response, calls for both disorders to be simultaneously targeted by the same clinician. The integrated model is more closely linked with the self-medication hypothesis, in which the SUD is primarily considered a means of reducing or self-medicating symptoms of PTSD and other negative affect (Khantzian, 1985). The integrated model posits that addressing the trauma early in treatment and providing concurrent relief from PTSD symptoms will likely improve recovery from SUDs (Back, 2010; Brady et al., 2001; Hien et al., 2010; Ouimette et al., 1997). Compelling support for this model is provided by investigations of the temporal course of symptom improvement. For example, in a study examining the temporal course of improvement in alcohol dependence symptoms and PTSD among 94 outpatients, improvements in PTSD symptoms had a greater impact on improvements in alcohol dependence symptoms, rather than the reciprocal relationship (Back et al., 2006). These findings were replicated by Hien and colleagues (2010) using data from a larger sample (N = 353) from a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) study. Only minimal evidence indicates that improvement in SUD symptoms results in improvement in PTSD; however, for every unit of PTSD improvement, the odds of being a heavy substance user at follow up decreases more than fourfold (Hein et al., 2010). In addition to a number of earlier case studies demonstrating that successful treatment of anxiety symptoms of PTSD leads to reductions in substance use (Fairbank & Keane, 1982; Fairbank et al., 1983; Keane & Kaloupek, 1982; Kilpatrick & Amick, 1985), the extant research examining the tolerability and efficacy of addressing PTSD among SUD patients show that substance use typically decreases significantly and does not increase with the addition of trauma-focused interventions (Back et al., 2012; Brady et al., 2001; Hien et al., 2010; McGovern et al., 2009; Mills et al., in press; Najavits et al., 2005; Triffleman, 2000). Furthermore, a large proportion of patients with comorbid PTSD and SUDs indicate that they would prefer to receive integrated treatment (Back, et al., 2006; Brown, et al., 1998; Najavits, Sullivan, Schmitz, Weiss, Lee, 2004). Given this growing evidence base and patient preference, the integrated model has received increasing support over the past decade (van Dam, Vedel, Ehring, & Emmelkamp, 2012). The subsequent sections on behavioral treatment will focus on two main types of integrated treatments: non exposure-based and exposure-based treatments (see Table 2).
Table 2.
Treatment | Exposure | Trial Design | Sample | Outcomes | Reference(s) |
---|---|---|---|---|---|
TREM | None |
Quasi- Experimental, Non-Equivalent Group TREM as part of a larger comprehensive treatment model v. TAU at community substance use treatment program; 6 and 12 month follow-up |
342 women with a trauma history and SUD, presenting for SUD treatment | Significantly greater reduction in drug use and PTSD symptoms among integrated treatment (including TREM) group compared to TAU |
Harris, 1998; Amaro et al., 2007 |
CBT for PTSD | None |
Open Pilot Trial Post-treatment and 3 month follow-up |
11 patients in community addictions treatment | Significant impact on PTSD symptoms and substance use; demonstrated feasibility of delivery in community addictions treatment facility | McGovern et al., 2009 |
Transcend | None |
Open Pilot Trial 6 and 12 month follow-up |
46 male Vietnam Veterans with PTSD and SUDs, presenting in partial hospitalization program | Significant improvements in PTSD symptoms across all follow- ups; Decreased substance use at follow-up | Donovan et al., 2001 |
Seeking Safety | None |
Uncontrolled Trial 3 month follow-up |
27 females with trauma history and SUD, recruited from the community | Among completers (n=17), significant improvements in substance use, trauma-related symptoms, suicide risk, depression, social adjustment, problem solving, family functioning, and cognitions about substance use. | Najavits, 1998 |
Uncontrolled Trial 3 month follow-up |
17 females with PTSD and SUD, incarcerated sample | Significant improvement in PTSD symptoms (53% no longer met criteria at post- treatment); Improvement in PTSD maintained at follow-up; Significant reductions in SUD symptoms, with only 35% reporting use within 3 months of prison release. | Zlotnick et al., 2003 | ||
Uncontrolled Trial Pre and Post only |
25 male and female Veterans with PTSD and SUD, presenting in outpatient Veterans Administration clinic | Significant improvements in self-reported PTSD symptoms, quality of life, communication, problem solving skills and abstinence at post- treatment | Cook et al., 2006 | ||
RCT SS and standard community care v. Relapse prevention and standard community care; 6 and 9 month follow- up |
107 females with PTSD or sub- threshold PTSD and SUD, presenting in community clinic | Significant reductions in SUDs and PTSD for both groups; PTSD symptoms still in moderate severity range; No group differences at follow-up | Hien et al., 2004 | ||
Uncontrolled Pilot SS plus Prolonged Exposure |
5 men with comorbid PTSD and substance dependence presenting at outpatient clinic | Significant improvements in drug use, trauma symptoms, psychosocial functioning, anxiety, & feelings/thoughts related to safety | Najavits et al., 2005 | ||
RCT SS and standard community care v. standard community care; 3 month follow-up |
33 adolescent girls with PTSD and SUD, recruited from community and community clinics | Significantly improved outcomes among SS group regarding attitudes toward substance use, some trauma- related symptoms, and associated pathology | Najavits et al., 2006 | ||
Quasi- Experimental SS v. wait list control |
107 females with PTSD or sub- threshold PTSD and SUD, low- income sample | Significant reductions in PTSD symptoms and alcohol use among SS v. wait list control; trend toward significant decrease in drug use for SS group | Cohen et al., 2006 | ||
Quasi- Experimental SS group v. TAU |
313 women with trauma history, substance use disorder and comorbid Axis I or Axis II disorder | SS group showed greater treatment retention over 3 months and greater improvement in PTSD symptoms and coping skills than TAU | Gatz et al., 2007 | ||
RCT SS and TAU v. TAU |
49 females with PTSD or sub- threshold PTSD and SUD, incarcerated sample | No significant differences between groups on all key domains; Both conditions showed significant improvements in PTSD and SUD symptoms across time | Zlotnick et al., 2009 | ||
RCT SS v. Women’s Health Education; 6, 9, and 12 month follow-up |
353 females with PTSD or sub- threshold PTSD and SUD, from national, multi-site community sample | Significant reduction in PTSD for both groups; No group differences on PTSD outcomes; No significant impact on abstinence at follow-up | Hien et al., 2009 | ||
Uncontrolled Pilot | 14 male OEF/OIF Veterans | Preliminary findings show significant reductions in PTSD symptoms and alcohol use | Norman et al., 2010 | ||
Controlled Trial SS v. wait list control |
114 incarcerated women reporting trauma history, history of SUD, and at least moderate PTSD symptoms | SS group demonstrated decreased depression, improved interpersonal functioning, and decreased maladaptive coping compared to control | Lynch et al., 2012 | ||
RCT SS v. TAU; 3 month follow-up |
98 male Veterans with PTSD and SUD (treatment as usual did not have to meet criteria for PTSD), presenting in outpatient Veterans Administration clinic | Significantly better drug use outcomes among SS than TAU; No differences between groups in alcohol use or PTSD symptom improvement | Boden et al., 2012 | ||
RCT SDPT v. 12 Step Facilitation; 1 month follow-up |
19 men and women with PTSD or sub- threshold PTSD and SUD, presenting in Methadone clinic | Significant improvement in SUD and PTSD severity for both groups; No differences between groups | Triffleman et al., 2000 | ||
SDPT | In vivo |
Open Pilot Trial 6 month follow-up |
39 men and women with PTSD and cocaine dependence, presenting for SUD treatment | Significant improvement in PTSD and cocaine dependence symptoms for completers; Improvements maintained at follow-up | Back et al., 2001; Brady et al., 2001 |
COPE | In vivo & Imaginal |
RCT COPE plus TAU v. TAU; 3 and 9 month follow-up |
103 men and women with PTSD and drug dependence, presenting for SUD treatment in Australia | Significant improvement in SUD and PTSD severity for both groups; Greater reduction in PTSD among treatment group | Mills et al., in press |
Case Study 3 and 6 month follow-up |
OEF/OIF male Veteran with PTSD and alcohol dependence | Preliminary findings show significant improvement in SUD and PTSD at end of treatment and both follow-up time points | Back et al., 2012 |
Note. TAU = Treatment as usual. Table does not represent an exhaustive review of all published trials of integrated treatment models.
Non Exposure-Based Integrated Treatments
Although Prolonged Exposure Therapy (Foa, Hembree, & Rothbaum, 2007) has been deemed one of the treatments of choice for PTSD (IOM, 2008), there is limited research exploring its efficacy in substance-abusing populations. As such, the majority of integrated treatment interventions that have been developed generally do not emphasize revisiting of traumatic memories (i.e., imaginal exposures) or confrontation of safe but anxiety producing situations in real life that are avoided by the patient (e.g., in vivo exposures). Rather, treatment tends to focus on the responses to the trauma and the impact of trauma symptoms. Treatment consists of psychoeducation, exploring the relationship between PTSD symptoms and substance use, self-management of symptoms and negative emotions, and development of cognitive behavioral coping skills. Some of these treatments separate the addiction treatment from the trauma work by the use of treatment phases, with the first phase dedicated to stabilizing the addiction in preparation for the second phase of working on the trauma. Examples of non exposure-based integrated treatments include Addictions and Trauma Recovery Integrated Model (ATRIUM; Miller & Guidry, 2001), CBT for PTSD (McGovern et al., 2009), and Trauma Affect Regulation: Guidelines for Education and Therapy (TARGET; Ford & Russo, 2006). Despite preliminary support for their efficacy in uncontrolled trials, limited empirical support exists to support the efficacy of these protocols in producing sustained improvements with respect to PTSD and SUD symptoms (SAMHSA, 2007).
Trauma-informed treatment in community substance abuse treatment programs is typically conducted in a group format and is often gender specific. The Trauma Exposure and Empowerment Model (TREM) was originally developed for women with trauma and severe mental disorders, including SUDs (Harris, 1998). The TREM intervention takes into account the differences in the way women experience and subsequently cope with trauma. Amaro et al. (2007) compared a comprehensive women’s substance abuse and co-occurring disorder treatment model that included a 25 session TREM intervention to treatment-as-usual in 342 women with a trauma history and SUD. Women in the intervention group showed significantly greater reductions in drug use and PTSD symptoms at the 12-month follow-up as compared to women in usual care. However, the study had limitations such as lack of randomization and lack of biological measures to verify abstinence. Because the TREM intervention was delivered as part of a comprehensive treatment package, it was difficult to attribute outcomes to the trauma intervention component.
Transcend, a 12-session manualized group treatment, consists of emphasis on the development of coping skills during the initial 6 sessions, followed by trauma processing conducted in the final 6 sessions (Donovan, Padin-Rivera, Kowaliw, 2001). Throughout treatment, substance use education, relapse prevention techniques, peer support, and 12 Step attendance is encouraged. In an open pilot trial among 46 male Vietnam Veterans participating in a partial hospitalization program, Transcend participants demonstrated significant improvement from baseline with respect to PTSD symptoms at post-treatment, 6, and 12 month follow-up. Transcend participants also experienced improvements in SUD symptoms, including decreased alcohol consumption, decreased polysubstance drug use, and decreased episodes of drinking to intoxication. Although these findings are promising, they remain preliminary, as Transcend has yet to be evaluated in a randomized controlled trial.
More rigorous research has been conducted with Seeking Safety (SS), a non exposure-based, manualized cognitive behavioral intervention for comorbid PTSD and SUDs (e.g., Najavits, 1998; Hien et al., 2004; 2008; additional studies summarized in Table 2). SS is a 24 session manualized therapy that prioritizes establishing and maintaining safety. Other key concepts include anticipating dangerous situations, setting boundaries, anger management and affect regulation. SS was compared to relapse prevention in a community sample of 107 women with SUDs and either PTSD or sub-threshold PTSD (Hien et al., 2004). Women were randomized to one of the two interventions and individual sessions were delivered twice weekly for 12 weeks. Compared to a nonrandomized community care group, both treatment interventions had improved substance use and PTSD severity outcomes at the end of treatment, and at 6 and 9 months follow-up. Of note, PTSD symptom severity scores as measured by the CAPS were still in the moderate severity range (score range 48–60) post treatment, and no significant differences in PTSD or SUD symptoms between the SS and relapse prevention groups were observed.
In a larger national multisite community study, SS was compared to a women’s health education (WHE) control group (Hien et al., 2009). Three hundred and fifty three women receiving standard community treatment as usual were randomized to 12 twice-weekly sessions of SS or WHE. Both interventions were delivered in a group format to more closely resemble how treatment is delivered in community programs. Both the SS and WHE groups significantly reduced PTSD symptoms. However, neither of the therapy groups had a significant impact upon abstinence rates over time. Interestingly, among women who had the largest reduction in PTSD symptom severity at the 12 month follow-up, those who received SS were more than twice as likely to be abstinent from substances than those who received WHE (43% versus 19%, respectively).
Non exposure-based integrated therapies have been more widely used in substance abuse community treatment programs, clearly indicating that clinicians see the necessity of addressing both SUDs and PTSD in the same treatment episode. However, treatment outcomes for both disorders have been modest at best and there is a need for improvement in treatment options.
Exposure-Based Integrated Treatments
Research has demonstrated that addressing trauma/PTSD among SUD patients is both tolerable and beneficial (Weis, 2010). Exposure-based therapies have been identified as one of the most effective forms of evidenced-based treatments available for PTSD (Ballenger et al., 2000; IOM, 2008). A recent meta-analysis of prolonged exposure therapy for PTSD found large effect sizes for prolonged exposure in comparison to control conditions (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010) and exposure-based therapies have demonstrated effectiveness in addressing PTSD among a variety of traumatic stress populations, including victims of rape, physical assault, refugees, motor vehicle accidents, combat, terrorism, childhood abuse, and mixed trauma types (Bryant et al., 2008; Foa et al., 2005; McDonagh et al., 2005; Nacasch et al., 2011, van Minnen et al., 2006; Resnick, Williams, Suvak, Monson & Gradus, 2012). A longitudinal study conducted 5–10 years after patients received prolonged exposure (N=65) demonstrated maintenance of effects with17.5% of patients meeting diagnostic criteria for PTSD (Resick, Williams, Suvak, Monson & Gradus, 2012).
Recently, prolonged exposure has been incorporated into existing residential SUD treatment with promising preliminary results (Berennz, Stasiewicz, Rowe, Schumacher, & Coffey, 2012; Henslee & Coffey, 2010). Berenz and colleagues (2012) completed a case series following outcomes of four individuals with PTSD in a residential substance use treatment facility. In addition to their standard residential SUD treatment, these individuals received 9 bi-weekly sessions of prolonged exposure, as well as in vivo and imaginal homework assignments between sessions. Post-treatment evaluations indicated that none of the individuals met criteria for PTSD, and this finding was maintained at 3 and 6-month follow-up. In addition, incorporation of prolonged exposure did not lead to increased rates of treatment dropout or relapse. Although preliminary, the findings support the feasibility of integrating prolonged exposure into residential SUD treatment facilities (see Henslee & Coffey, 2010).
In addition to the incorporation of prolonged exposure therapy into residential SUD treatment, two integrated treatments that incorporate exposure-based techniques have been tested among individuals with PTSD and SUDs. Triffleman and colleagues (1999 PTSD and SUDs. Triffleman and colleagues (2000) developed an integrated treatment, Substance Dependence Posttraumatic Stress Disorder Therapy (SDPT) delivered as a five-month intervention, including twice-weekly sessions. SDPT incorporates a two-phased approach that includes an integration of cognitive-behavioral treatment for SUD with in vivo exposure for PTSD. When compared to a Twelve-Step Facilitation Therapy which did not address trauma, among a sample of 19 methadone-maintained patients, improvements were observed with respect to both SUD and PTSD symptom severity; however, no between group differences were observed. Several reasons were posited for the lack of differential findings, including the small sample size, the short follow-up period (1 month) and the fact that SDPT did not incorporate imaginal exposure (i.e., exposure to the memories of past trauma), and instead only integrated in vivo exposure.
Subsequent to the evaluation of SDPT, Brady and colleagues developed a concurrent treatment for PTSD and co-occurring cocaine dependence (Brady et al., 2001; Back et al., 2001). The treatment, currently referred to as COPE (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure) is the first treatment to combine evidence-based cognitive behavioral therapy for SUDs (Carroll, 1998) with the key components of prolonged exposure for PTSD (Foa et al., 2007), which includes both in vivo and imaginal exposure techniques. The PTSD treatment component of COPE is designed to help patients understand the relationship between PTSD and substance use, normalize common reactions to trauma, and reduce PTSD symptoms via exposure techniques, whereas the substance use treatment component of COPE is designed to help patients recognize and manage cravings and urges to use alcohol or drugs, manage thoughts about substance use, identify and plan for “high-risk” situations in which vulnerability to relapse is heightened, and effectively manage a potential lapse (Carroll, 1998). COPE was initially trialed as an individual, 16-session intervention, which included in vivo exposure (sessions 6–15) and imaginal exposure (sessions 7–15), in an uncontrolled psychotherapy development study among patients (N = 39) presenting with comorbid PTSD and cocaine dependence (Brady et al., 2001). In this preliminary study, participation in exposure-based techniques was not associated with escalation of substance use or increased risk of relapse; however, attrition was high, as with other studies employing only substance abuse treatments in this population (Chris-Christoph et al., 1999). Interestingly, the majority of participants who dropped out of treatment (75% of dropouts) did so before the initiation of exposure procedures. Fifteen participants (38.5%) were categorized as treatment completers, defined a priori as patients who attended at least 10 sessions (63% of sessions) and received at least 3 imaginal exposures. The average number of sessions attended was 14.7 for treatment completers and 4.1 for treatment non-completers. Completers of the program demonstrated significant improvements in all PTSD symptom clusters (i.e., re-experiencing, avoidance, hyperarousal) and reduction of cocaine use from baseline to end of treatment (Brady et al., 2001). Further, reductions in PTSD and SUD symptoms were maintained at 6-month follow-up and COPE also produced significant sustained reductions in depression.
Mills and colleagues (in press) recently completed a randomized control trial of COPE plus treatment as usual (TAU) vs. TAU alone. TAU consisted of detoxification and inpatient and/or outpatient drug counseling. Participants were 103 patients (62.1% female) with civilian PTSD and SUDs. Most patients evidenced poly-substance use (using a median of 4.0 different drug classes in the preceding month). The most commonly reported substances were heroin (21.4%), cannabis (19.4%), amphetamines (17.5%), benzodiazepines (15.5%). For this trial, COPE consisted of 13, individual, 90-minute sessions. Treatment components included: motivational interviewing and CBT for substance use; psychoeducation regarding to both disorders and their interaction; in vivo exposure (sessions 5–12); imaginal exposure (sessions 6–12); and cognitive therapy for PTSD. The final session (session 13) provided a review of the treatment and developed an after care plan. From baseline to 9-month follow-up, significant reductions in PTSD symptom severity were found for both groups, however, the COPE group demonstrated a significantly greater reduction in PTSD symptom severity (mean difference −16.09) and lower rates of PTSD diagnosis as compared to the control group (56.4% vs. 79.2%). No significant between group differences in rates of abstinence or number of SUD dependence criteria met were observed. At the 9-month follow-up visits, rates of SUD diagnosis had dropped to 45.4% in the COPE group and 56.2% in the control group. Retention did not differ by group. In sum, findings from this first randomized controlled trial of COPE demonstrate that treatments utilizing prolonged exposure therapy for PTSD: (1) can be used safely with patients with co-occurring SUDs and do not lead to an increase in substance use; (2) demonstrate sustained improvements across all outcome domains; and (3) produce greater improvements in PTSD than treatment as usual.
Currently, COPE is being evaluated versus standard cognitive-behavioral relapse prevention in a randomized controlled trial among OEF/OIF Veterans. Since its inception, the intervention has been modified to address all substances of abuse and currently consists of 12 individual, 90-minute sessions that include a substance abuse and PTSD component (Back et al., 2012; Killeen, Back, & Brady, 2011). In vivo exposures are now conducted in sessions 3–11 and imaginal exposures in sessions 4–11. Although preliminary, initial findings demonstrate COPE’s ability to produce significant and sustained symptom reduction, and lend support for the acceptability and tolerability of the COPE treatment among a Veteran population (Back et al., 2012).
In summary, PTSD and SUDs commonly co-occur and both non exposure-based and exposure-based integrated interventions have been shown to be safe and effective. Although non exposure-based treatments offer some PTSD symptom reduction, exposure-based treatments including both in vivo and imaginal exposure techniques may offer greater symptom reduction. The recent evidence showing improvement in PTSD positively impacting substance use outcomes clearly supports a more rigorous approach to assessing and treating PTSD among patients with SUDs. It is important to note that, at present, the variables which may predict a more favorable response to integrated treatment (including patient, trauma, or substance related variables) are unclear. In selecting a treatment approach, a number of factors may be considered (see Killeen et al., 2011 for more details), such as, patient preference, history of treatment and treatment response, severity of SUD, withdrawal symptom severity and need for medically supervised detoxification, and ability of the patient to recall the trauma memory (necessary for exposure-based treatments). In addition, clinicians should consider the functional relationship between PTSD and SUD symptoms for each patient. Clinicians will want to obtain information regarding the exact reasons why each patient reports using substances (e.g., to sleep better and not remember trauma-related memories, to block out memories or flashbacks, to be able to engage in social interactions) and use this information to inform treatment selection and implementation.
Pharmacological Treatment of PTSD and SUDs
Studies of medications in the treatment of co-occurring PTSD and SUDs are lacking. Sertaline, a serotonin-reuptake inhibitor which has received FDA-approval for the treatment of PTSD, was investigated in a double-blind, placebo-controlled, 12-week trial (Brady et al., 2005). The study demonstrated that individuals with early age of onset PTSD (i.e., childhood trauma) and less severe alcohol dependence demonstrated more favorable improvements in alcohol use severity when treated with sertraline as compared to placebo. In contrast, individuals with later age of onset PTSD and more severe alcohol dependence evidenced more favorable alcohol use outcomes when treated with placebo as compared to sertraline. The sertraline-treated group also showed a trend toward greater PTSD improvement as compared to the placebo-treated group. Petrakis and colleagues (2005) investigated the use of two agents which target alcohol consumption, disulfiram and naltrexone, alone or in combination, in a 12-week controlled trial in outpatients with alcohol dependence (AD) and a variety of comorbid psychiatric disorders (42.9% met DSM-IV criteria for comorbid PTSD). Patients treated with either medication evidenced more consecutive weeks of abstinence and fewer drinking days as compared to patients on placebo. Individuals treated with disulfram reported less craving from pre to post treatment as compared to naltrexone-treated individuals. In addition, individuals receiving active medication demonstrated greater symptom improvement (e.g., less anxiety) pre to post treatment as measured by the Brief Symptom Inventory. No advantage of combining disulfiram and naltrexone was reported. In a more recent study (Petrakis et al., 2011), the serotonin uptake inhibitor, paroxetine, was compared to the norepinephrine uptake inhibitor, desipramine in 88 male veterans who met current diagnostic criteria for both AD and PTSD. Subjects were randomly assigned under double-blind conditions to one of four groups: paroxetine + naltrexone; paroxetine + placebo; desipramine + naltrexone; desipramine + placebo.
Paroxetine did not show statistical superiority to desipramine for the treatment of PTSD symptoms. However, desipramine was superior to paroxetine with respect to study retention and alcohol use outcomes. Naltrexone reduced alcohol craving relative to placebo, but it conferred no advantage on drinking use outcomes. Although the serotonin uptake inhibitors are the only FDA-approved medications for the treatment of PTSD, the current study suggests that norepinephrine uptake inhibitors may present clinical advantages when treating male veterans with PTSD and AD. Further investigation of the use of medications as an adjunct to psychotherapeutic treatment in the treatment of co-occurring PTSD and SUDs are needed.
Conclusions
The comorbid presentation of PTSD and SUDs is remarkably common, and in comparison to patients presenting with either PTSD or SUD alone, PTSD/SUD patients often report greater functional impairment and experience poorer treatment outcomes –including treatment failure and dropout. Several mechanisms have been posited to explain the co-occurrence of PTSD and SUDs, including the self-medication hypothesis, the high-risk hypothesis, the susceptibility hypothesis. The majority of research to date supports the self-medication hypothesis.
At present, a wide array of assessment tools exist that allow for the efficient and effective screening, diagnosis and symptom monitoring. The availability of such a range of assessment options make both the regular integration of trauma screening into traditional SUD treatment settings, as well as the integration of SUD screening into traditional trauma-focused treatment settings, a viable and worthwhile standard operating procedure among practitioners.
In addition, there is a growing arsenal of available treatment options to concurrently address PTSD and SUD symptoms. Whereas PTSD and SUD have historically been treated using the sequential treatment model, the integrated treatment model has garnered increasing empirical support over the past decade. A handful of integrated treatments have been evaluated in uncontrolled and randomized controlled trials with overall promising findings. In addition to being well tolerated by patients, integrated treatments have demonstrated the ability to significantly reduce symptoms of PTSD, SUD and associated pathology such as depression. Perhaps most promising are integrated treatments that incorporate exposure-based techniques – the recognized “gold standard” in PTSD treatment (IOM, 2008) – with cognitive behavioral treatment of substance use disorders. It is important to note, however, that while evidence for the efficacy and effectiveness of integrated, exposure-based treatments (such as COPE) is growing, the research in this area is still in a nascent state. Continued research is needed in the form of randomized controlled efficacy trials among variant high-risk populations. In line with recommendations from a recent systematic review of integrated treatments for PTSD/SUD (vanDam et al., 2012), future research should attend to the methodological rigor of clinical trials by ensuring adequate randomization, using an active comparison condition, and including long-term follow-ups to establish the sustainability of treatment outcomes. Further, research on the exportability and effectiveness of integrated treatments is needed in a range of settings (e.g., Veterans Administration hospitals, SUD treatment facilities, traditional mental health departments) to ensure that evidence-based best practices are widely accessible.
Acknowledgments
The authors would like to acknowledge support from NIDA grant DA030143 (SEB).
References
- Aithal GP, Thornes H, Dwarakanath AD, Tanner AR. Measurement of carbohydrate-deficient transferring (CDT) in a general medical clinic: Is this test useful in assessing alcohol consumption? Alcohol & Alcoholism. 1998;33(3):304–309. doi: 10.1093/oxfordjournals.alcalc.a008394. [DOI] [PubMed] [Google Scholar]
- Amaro H, Dai J, Arevalo S, Acevedo A, Mastsumoto A, Nieves R. Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban community-based substance abuse treatment. Journal of Urban Health. 2007;84:508–522. doi: 10.1007/s11524-007-9160-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4. Washington DC: Author; 2000. text revision. [Google Scholar]
- Annis HM. Inventory of drinking situations. Toronto: Addiction Research Foundation of Ontario; 1982. [Google Scholar]
- Annis HM, Martin G. Inventory of Drug-Taking Situations. Toronto, Canada: Addiction Research Foundation; 1985. [Google Scholar]
- Annis HM, Turner NE, Sklar SM. Inventory of Drug-Taking Situations: User’s Guide. Toronto, Canada: Addiction Research Foundation, Centre for Addiction and Mental Health; 1997. [Google Scholar]
- Arndt T. Carbohydrate-deficient transferrin as a marke of chronic alcohol abuse: A critical review of preanalysis, analysis, and interpretation. Clinical Chemistry. 2001;47(1):13–27. Retrived from http://www.clinchem.org. [PubMed] [Google Scholar]
- Back SE. Toward an improved model of treating co-occurring PTSD and substance use disorders. American Journal of Psychiatry. 2010;167:11–13. doi: 10.1176/appi.ajp.2009.09111602. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Back SE, Brady KT, Jaanimagi U, Jackson JL. Cocaine dependence and PTSD: a pilot study of symptom interplay and treatment preferences. Addictive Behaviors. 2006;31:351–354. doi: 10.1016/j.addbeh.2005.05.008. [DOI] [PubMed] [Google Scholar]
- Back SE, Brady KT, Sonne SC, Verduin ML. Symptom improvement in co-occurring PTSD and alcohol dependence. Journal of Nervous and Mental Disease. 2006;194(9):690–696. doi: 10.1097/01.nmd.0000235794.12794. [DOI] [PubMed] [Google Scholar]
- Back SE, Dansky BS, Carroll KM, Foa EB, Brady KT. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: description of procedures. Journal of Substance Abuse Treatment. 2001;21(1):35–45. doi: 10.1016/S0740-5472(01)00181-7. [DOI] [PubMed] [Google Scholar]
- Back SE, Dansky BS, Coffey SF, Saladin ME, Sonne SC, Brady KT. Cocaine dependence with and without posttraumatic stress disorder: A comparison of substance use, trauma history, and psychiatric comorbidity. American Journal on Addictions. 2000;9:51–62. doi: 10.1080/10550490050172227. [DOI] [PubMed] [Google Scholar]
- Back SE, Jackson JL, Sonne SC, Brady KT. Alcohol dependence and posttraumatic stress disorder: differences in clinical presentation and response to cognitive-behavioral therapy by order of onset. Journal of Substance Abuse Treatment. 2005;29:29–37. doi: 10.1016/j.jsat.2005.03.002. [DOI] [PubMed] [Google Scholar]
- Back SE, Killeen T, Foa EB, Santa Ana EJ, Gros DF, Brady KT. Use of an integrated therapy with prolonged exposure to treat PTSD and comorbid alcohol dependence in an Iraq veteran. American Journal of Psychiatry. 2012;169(7):688–691. doi: 10.1176/appi.ajp.2011.11091433. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ballenger JC, Davidson JRT, Lecrubier Y, Nutt D, Foa EB, Kessler RC, McFarlane AC. Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry. 2000;61(suppl 5):60–66. Retrieved from http://www.psychiatrist.com. [PubMed] [Google Scholar]
- Berenz EC, Stasiewicz PR, Rowe L, Schumacher JA, Coffey SF. Prolonged exposure therapy for posttraumatic stress disorder among individuals in a residential substance use treatment program: A case series. Professional Psychology: Research and Practice. 2012;43(2):154–161. doi: 10.1037/a0026138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Berman AH, Bergman H, Palmstierno T, Schlyter F. Evaluation of the Drug Use Disorders Identification Test (DUDIT) in criminal justice and detoxification settings and in a Swedish population sample. European Addiction Research. 2005;11:22–31. doi: 10.1159/000081413. [DOI] [PubMed] [Google Scholar]
- Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, Keane TM. The development of a clinician-administered PTSD scale. Journal of Traumatic Stress. 1995;8:75–90. doi: 10.1002/jts.2490080106. [DOI] [PubMed] [Google Scholar]
- Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL) Behaviour Research Therapy. 1996;34:669–673. doi: 10.1016/0005-7967(96)00033-2. [DOI] [PubMed] [Google Scholar]
- Boden MT, Kimerling R, Jacobs-Lentz J, Bowman D, Weaver C, Carney D, Walser R, Trafton JA. Seeking Safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction. 2012;107:578–586. doi: 10.1111/j.1360-0443.2011.03658.x. [DOI] [PubMed] [Google Scholar]
- Brady KT, Back SE, Coffey SF. Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science. 2004;13:206–209. doi: 10.1111/j.0963-7214.2004.00309.x. [DOI] [Google Scholar]
- Brady KT, Dansky BS, Back SE, Foa AB, Carroll KM. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings. Journal of Substance Abuse Treatment. 2001;21:47–54. doi: 10.1016/S0740-5472(01)00182-9. [DOI] [PubMed] [Google Scholar]
- Brady KT, Dansky BS, Sonne SC, Saladin ME. Posttraumatic stress disorder and cocaine dependence e order of onset. American Journal on Addictions. 1998;7:128–135. doi: 10.1111/j.1521-0391.1998.tb00327.x. [DOI] [PubMed] [Google Scholar]
- 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(3):395–401. doi: 10.1097/01.ALC.0000156129.98265.57. [DOI] [PubMed] [Google Scholar]
- Bray RM, Hourani LL. Substance use trends among active duty military personnel: Findings from the United Stated Department of Defense Health Related Behavior Surveys, 1980–2005. Addiction. 2007;102:1092–1101. doi: 10.1111/j.1360-0443.2007.01841.x. [DOI] [PubMed] [Google Scholar]
- Brewin CR, Rose S, Andrews B, Green J, Tata P, McEvedy C, Turner S, Foa EB. Brief screening instrument for post-traumatic stress disorder. The British Journal of Psychiatry. 2002;181:158–162. doi: 10.1017/s0007125000161896. Retrieved from http://bjp.rcpsych.org. [DOI] [PubMed] [Google Scholar]
- Brown PJ, Stout RL, Gannon-Rowley J. Substance use disorder-PTSD comorbidity. Patients’ perceptions of symptom interplay and treatment issues. Journal of Substance Abuse Treatment. 1998;15(5):445–448. doi: 10.1016/S0740-5472(97)00286-9. [DOI] [PubMed] [Google Scholar]
- Bryant RA, Moulds ML, Guthrie RM, Dang ST, Mastrodomenico J, Nixon RDV, et al. A randomized controlled trial of exposure therapy and cognitive restructuring in treatment for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 2008;71(4):706–712. doi: 10.1037/0022-006X.71.4.706. [DOI] [PubMed] [Google Scholar]
- Bufka LF, Camp N. Brief measures for screening and measuring mental health outcomes. In: Antony MM, Barlow DH, editors. Handbook of assessment and treatment planning for psychological disorders. 2. New York, NY: Guilford; 2011. pp. 62–94. [Google Scholar]
- Carroll KM. NIDA Therapy Manuals for Drug Addiction. Rockville, MD: National Institute on Drug Abuse; 1998. A cognitive-behavioral approach: Treating cocaine addiction. NIH Pub No. 98-4308. [Google Scholar]
- Centers for Disease Control Vietnam Experience Study. Health status of Vietnam veterans: I. Psychosocial characteristics. Journal of the American Medical Association. 1988;259:2701–2707. doi: 10.1001/jama.1988.03720180027028. [DOI] [PubMed] [Google Scholar]
- Chilcoat HD, Breslau N. Investigations of causal pathways between PTSD and drug use disorders. Addictive Behaviors. 1998;23(6):827–840. doi: 10.1016/S0306-4603(98)00069-0. [DOI] [PubMed] [Google Scholar]
- Chilcoat H, Menard C. Epidemiological investigations: Co-morbidity of posttraumatic stress disorder and substance use disorder. In: Ouimette P, Brown P, editors. Trauma and substance use. Washington, D.C: American Psychological Association; 2003. pp. 9–28. [Google Scholar]
- 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 and Alcohol Dependence. 2002;65:115–127. doi: 10.1016/S0376-8716(01)00157-0. [DOI] [PubMed] [Google Scholar]
- Coffey SF, Schumacher JA, Brady KT, Cotton BD. Changes in PTSD symptomatology during acute and protracted alcohol and cocaine abstinence. Drug and Alcohol Dependence. 2007;87:241–248. doi: 10.1016/j.drugalcdep.2006.08.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 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. Psychology of Addictive Behaviors. 2006;20(4):425–435. doi: 10.1037/0893-164X.20.4.425. [DOI] [PubMed] [Google Scholar]
- Cohen LR, Hien DA. Treatment outcomes for women with substance abuse and PTSD who have experienced complex trauma. Psychiatric Services. 2006;57(1):100–106. doi: 10.1176/appi.ps.57.1.100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Compton WM, Cottler LB, Phelps DL, Abdallah AB, Spitznagel EL. Psychiatric disorders among drug dependent subjects: Are they primary or secondary? The American Journal on Addictions. 2000;9:126–134. doi: 10.1080/10550490050173190. [DOI] [PubMed] [Google Scholar]
- Connor K, Davidson J. SPRINT: A brief global assessment of post-traumatic stress disorder. International Clinical Psychopharmacology. 2001;16:279–284. doi: 10.1097/00004850-200109000-00005. [DOI] [PubMed] [Google Scholar]
- Cook JM, Walser RD, Kane V, Ruzek JI, Woody G. Dissemination and feasibility of a cognitive-behavioral treatment for substance use disorders and posttraumatic stress disorder in the Veterans Administration. Journal of Psychoactive Drugs. 2006;38:89–92. doi: 10.1080/02791072.2006.10399831. [DOI] [PubMed] [Google Scholar]
- Cooney NL, Zweben A, Fleming MF. Screening for alcohol problems and at-risk drinking in health care settings. In: Hester RK, Miller WR, editors. Handbook of alcoholism treatment approaches: Effective alternatives. 2. Needham Heights, MA: Allyn & Bacon; 1995. pp. 45–60. [Google Scholar]
- Cooper ML. Motivations for alcohol use among adolescents: Development and validation of a four-factor model. Psychological Assessment. 1994;6:117–128. doi: 10.1037/1040-3590.6.2.117. [DOI] [Google Scholar]
- Cottler LB, Compton WM, Mager D, Spitznagel EL, Janca A. Post-traumatic stress disorder among substance abusers from the general population. American Journal of Psychiatry. 1992;149:664–670. doi: 10.1176/ajp.149.5.664. Retrieved from http://ajp.psychiatryonline.org/journal.aspx?journalid=13. [DOI] [PubMed] [Google Scholar]
- Crits-Christoph P, Siqueland L, Blaine J, Frank A, Luborsky L, Onken LS, Muenz LR, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment. Archives of General Psychiatry. 1999;56:493–502. doi: 10.1001/archpsyc.56.6.493. [DOI] [PubMed] [Google Scholar]
- Dansky BS, Brady KT, Roberts JT. Post-traumatic stress disorder and substance abuse: Empirical findings and clinical issues. Substance Abuse. 1994;15(4):247–257. Retrieved from http://www.tandfonline.com/toc/wsub20/current. [Google Scholar]
- Di Nardo PA, Brown TA, Barlow DH. Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L) San Antonio, TX: Psychological Corporation; 1994. [Google Scholar]
- Donovan B, Padin-Rivera E, McCormick R. Transcend manual: Therapist guidelines for the treatment of combat-related PTSD. 3. Brecksville, OH: Louis Stokes Cleveland Department of Veteran Affairs Medical Center, Brecksville Division; 1997. [Google Scholar]
- Donovan B, Padin-Rivera E, Kowaliw S. “Transcend”: Initial outcomes from a posttraumatic stress disorder/substance abuse treatment program. Journal of Traumatic Stress. 2001;14(4):757–772. doi: 10.1023/A:1013094206154. [DOI] [PubMed] [Google Scholar]
- Driessen M, Schulte S, Luedecke C, Schaefer I, Sutmann F, Ohlmeier M, Kemper U, Koesters G, Chodzinski C, Schneider U, Broese T, Dette C, Havemann-Reinicke U. Trauma and PTSD in patients with alcohol, drug, or dual dependence: a multi-center study. Alcohol Clinical and Experimental Research. 2008;32:481–488. doi: 10.1111/j.1530-0277.2007.00591.x. [DOI] [PubMed] [Google Scholar]
- Fairbank JA, Gross RT, Jeane TM. Treatment of posttraumatic stress disorder: Evaluating outcome with a behavioral code. Behavior Modification. 1983;7:557–568. doi: 10.1177/01454455830074005. [DOI] [PubMed] [Google Scholar]
- Fairbank JA, Keane TM. Flooding for combat-related stress disorders: Assessment of anxiety reduction across traumatic memories. Behavior Therapy. 1982;13:499–510. doi: 10.1016/S0005-7894(82)80012-9. [DOI] [Google Scholar]
- Fallot RD, Harris M. The Trauma Recovery and Empowerment Model (TREM): conceptual and practical issues in a group intervention for women. Community Mental Health Journal. 2002;38:475–485. doi: 10.1023/A:1020880101769. [DOI] [PubMed] [Google Scholar]
- First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders – Clinician version (SCID-I/P, Version 2.0) New York: New York Psychiatric Institute, Biometrics Research Department; 1996. [Google Scholar]
- Foa EB, Hembree EA, Rothbaum BO. Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Oxford: Oxford University Press; 2007. [Google Scholar]
- Foa EB, Hembree EA, Cahill SP, Rauch SA, Riggs DS, Feeny NC, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring; Outcomes at academic and community centers. Journal of Consulting and Clinical Psychology. 2005;73(5):953–964. doi: 10.1037/0022-006X.73.5.953. [DOI] [PubMed] [Google Scholar]
- Foa EB, Riggs D, Dancu C, Rothbaum BO. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress. 1993;6:459–474. doi: 10.1002/jts.2490060405. [DOI] [Google Scholar]
- Ford JD, Russo EM. Trauma-focused, present-centered, emotional self-regulation approach to integrated treatment for posttraumatic stress and addiction: Trauma Adaptive Recovery Group Education and Therapy (TARGET) American Journal of Psychotherapy. 2006;60(4):335–355. doi: 10.1176/appi.psychotherapy.2006.60.4.335. Retrieved from http://search.ebscohost.com. [DOI] [PubMed] [Google Scholar]
- Ford JD, Russo EM, Mallon SD. Integrating treatment of posttraumatic stress disorder and substance use disorder. Journal of Counseling and Development. 2007;85:475–489. doi: 10.1002/j.1556-6678.2007.tb00616.x. [DOI] [Google Scholar]
- Gatz M, Brown V, Hennigan K, Rechberger E, O’Keefe M, Rose T, Bjelejac P. Effectiveness of an integrated trauma-informed approach to treating women with co-occurring disorders and histories of trauma. Journal of Community Psychology. 2007;35:863–878. doi: 10.1002/jcop.20186. [DOI] [Google Scholar]
- Gavin DR, Ross HE, Skinner H. Diagnostic validity of the Drug Abuse Screening Test in the assessment of DSM-III drug disorders. British Journal of Addictions. 1989;84:301–307. doi: 10.1111/j.1360-0443.1989.tb03463.x. [DOI] [PubMed] [Google Scholar]
- Grant BF, Hasin DS. The Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS) Rockville, MD: National Institute of Alcohol Abuse and Alcoholism; 1990. [Google Scholar]
- Grant VV, Stewart SH, O’Connor RM, Blackwell E, Conrod PJ. Psychometric evaluation of the five-factor Modified Drinking Motives Questionnaire – Revised in undergraduates. Addictive Behaviors. 2007;32:2611–2632. doi: 10.1016/j.addbeh.2007.07.004. [DOI] [PubMed] [Google Scholar]
- Gray MJ, Elhai JD, Owen JR, Monroe R. Psychometric properties of the Trauma Assessment for Adults. Depression and Anxiety. 2009;26:190–195. doi: 10.1002/da.20535. [DOI] [PubMed] [Google Scholar]
- Gray MJ, Litz BT, Hsu JL, Lombardo TW. Psychometric properties of the Life Events Checklist. Assessment. 2004;11:330–341. doi: 10.1177/1073191104269954. [DOI] [PubMed] [Google Scholar]
- Gros DF, Simms LJ, Antony MM, McCabe RE. Development and psychometric evaluation of the Multidimensional Assessment of Social Anxiety (MASA) Journal of Clinical Psychology. 2012;68:432–447. doi: 10.1002/jclp.21838. [DOI] [PubMed] [Google Scholar]
- Harris M. Trauma recovery and empowerment: A clinician’s guide for working with women in groups. New York: The Free Press; 1998. [Google Scholar]
- Henslee AM, Coffey SF. Exposure therapy for posttraumatic stress disorder in a residential substance use treatment facility. Professional Psychology: Research and Practice. 2010;41(1):34–40. doi: 10.1037/a0018235. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hien DA, Campbell ANC, Ruglass L, Hu MC, Killeen T. The role of alcohol misuse on PTSD outcomes for women in community treatment: A secondary analysis of NIDA’s Women and Trauma study. Drug and Alcohol Dependence. 2010;111:114–119. doi: 10.1016/j.drugalcdep.2010.04.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hien DA, Cohen LR, Miele GM, Litt LC, Capstick C. Promising treatments for women with comorbid PTSD and substance use disorders. American Journal of Psychiatry. 2004;161:1426–1432. doi: 10.1176/appi.ajp.161.8.1426. [DOI] [PubMed] [Google Scholar]
- Hien DA, Jiang H, Campbell ANC, Hu MC, Miele GM, Cohen LR, Brigham GS, Captick C, Kulaga A, Robinson J, Suarez-Morales L, Nunes EV. Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s clinical trials network. American Journal of Psychiatry. 2010;167:95–101. doi: 10.1176/appi.ajp.2009.09091261. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hien D, Wells EA, Jiang H, Suarez-Morales L, Campbell A, Cohen L, Miele G, Killeen T, Brighman G, Zhang Y, Hansen C, Hodgkins C, Hatch-Maillette M, Brown C, Kulaga A, Kristman-Valente A, Chu M, Sage R, Robinson J, Liu D, Nunes EV. Multi-site randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. Journal of Consulting and Clinical Psychology. 2009;77(4):607–619. doi: 10.1037/a0016227. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine. 2004;351(1):13–22. doi: 10.1056/NEJMoa040603. [DOI] [PubMed] [Google Scholar]
- Humeniuk RE, Ali RL, Babor F, Farrell M, Formigoni KL, Jittiwutikarn J, de Lacerda RB, Ling W, Marsden J, Monteiro M, et al. Validation of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) Addiction. 2008;103(6):1039–1047. doi: 10.1111/j.1360-0443.2007.02114.x. [DOI] [PubMed] [Google Scholar]
- Institute of Medicine, Committee on Treatment of Posttraumatic Stress. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, D.C: The National Academies Press; 2008. [Google Scholar]
- Jacobsen LK, Southwick SM, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry. 2001;158:1184–1190. doi: 10.1176/appi.ajp.158.8.1184. [DOI] [PubMed] [Google Scholar]
- Jaffe SL. Adolescent substance abuse: Assessment and treatment. In: Esman AH, Flaherty LT, Horowitz HA, editors. Adolescent psychiatry: Developmental and clinical studies. Vol. 23. Mahwah, NJ US: Analytic Press; 1998. pp. 61–71. [Google Scholar]
- Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Posttraumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiology. 2003;157(2):141–148. doi: 10.1093/aje/kwf187. [DOI] [PubMed] [Google Scholar]
- Keane TM, Kaloupek DG. Imaginal flooding in the treatment of a posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 1982;50:138–140. doi: 10.1037/0022-006X.50.1.138. [DOI] [PubMed] [Google Scholar]
- Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62(6):593–602. doi: 10.1001/archpsyc.62.6.593. [DOI] [PubMed] [Google Scholar]
- Kessler R, Sonnega A, Bromet E, Hughes M, Nelson C. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry. 1995;52(12):1048–1060. doi: 10.1001/archpsyc.1995.03950240066012. [DOI] [PubMed] [Google Scholar]
- Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. American Journal of Psychiatry. 1985;142(11):1259–1264. doi: 10.1176/ajp.142.11.1259. Retrieved from http://ajp.psychiatryonline.org/journal.aspx?journalid=13. [DOI] [PubMed] [Google Scholar]
- Khantzian EJ. Self-regulation and self-medication factors in alcoholism and t he addictions: Similarities and differences. In: Galanter M, editor. Recent developments in alcoholism, Vol. 8: Combined alcohol and other drug dependence. New York, NY US: Plenum Press; 1990. pp. 255–271. [PubMed] [Google Scholar]
- Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications.[see comment] Harvard Review of Psychiatry. 1997;4(5):231–244. doi: 10.3109/10673229709030550. [DOI] [PubMed] [Google Scholar]
- Khoury L, Tang YL, Bradley B, Cubells JF, Ressler KJ. Substance use, childhood traumatic experience and posttraumatic stress disorder in an urban civilian population. Depression and Anxiety. 2010;27:1077–1086. doi: 10.1002/da.20751. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Killeen T, Back SE, Brady KT. The use of exposure-based treatment among individuals with PTSD and co-occurring substance use disorders: Clinical considerations. Journal of Dual Diagnosis. 2011;7(4):194–206. doi: 10.1080/15504263.2011.620421. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kilpatrick DG, Amick AE. Rape trauma. In: Hersen M, Last CG, editors. Behavior therapy casebook. New York: Springer; 1985. pp. 86–103. [Google Scholar]
- Kingston S, Raghavan C. The relationship of sexual abuse, early initiation of substance use, and adolescent trauma to PTSD. Journal of Traumatic Stress. 2009;22:65–68. doi: 10.1002/jts.20381. [DOI] [PubMed] [Google Scholar]
- Kubany ES, Leisen MB, Kaplan AS, Watson SB, Haynes SN, Owens JA, Burns K. Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The Traumatic Life Events Questionnaire. Psychological Assessment. 2000;12:210–224. doi: 10.1037/1040-3590.12.2.210. [DOI] [PubMed] [Google Scholar]
- Lang AJ, Stein MB. An abbreviated PTSD checklist for use as a screening instrument in primary care. Behaviour Research and Therapy. 2005;43:585–594. doi: 10.1016/j.brat.2004.04.005. [DOI] [PubMed] [Google Scholar]
- Lauterbach D, Vrana SR. Three studies on the reliability and validity of a self-report measure of posttraumatic stress disorder. Assessment. 1996;3:17–25. Retrieved from http://asm.sagepub.com. [Google Scholar]
- Lynch SM, Heath NM, Matthews KC, Cepeda GJ. Seeking Safety: An intervention for trauma exposed incarcerated women? Journal of Trauma and Dissociation. 2012;13:88–101. doi: 10.1080/15299732.2011.608780. [DOI] [PubMed] [Google Scholar]
- McLellan AT, Luborsky L, Woody GE, O’Brien CP. An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disorders. 1980;168:26–33. doi: 10.1097/00005053-198001000-00006. [DOI] [PubMed] [Google Scholar]
- McLellan AT, Kushner H, Metzger D, Peters R, Grisson G, Pettinati H, Argeriou M. The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment. 1992;9(3):199–213. doi: 10.1016/0740-5472(92)90062-S. [DOI] [PubMed] [Google Scholar]
- McDonagh A, Friedman M, McHugo G, Ford J, Sengupta A, Mueser K, Demment CC, et al. Randomized trial of cognitive behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. Journal of Consulting and Clinical Psychology. 2005;73(3):515–24. doi: 10.1037/0022-006X.73.3.515. [DOI] [PubMed] [Google Scholar]
- McGovern MP, Lambert-Harris C, Acquilano S, Xie H, Alterman AI, Weiss RD. Cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders. Addictive Behaviors. 2009;34:892–897. doi: 10.1016/j.addbeh.2009.03.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Miller D, Guidry L. Addictions and Trauma Recovery: Healing the Body, Mind and Spirit. New York, NY US: W.W. Norton & Company; 2001. [Google Scholar]
- Miller WR, Tonigan JS, Longabaugh R. Project Match Monograph Series. Vol. 4. Rockville, MD: National Institute of Alcohol Abuse and Alcoholism; 1995. The Drinker Inventory of Consequences (DrinC): An instrument for assessing adverse consequences of alcohol abuse: Test manual. [Google Scholar]
- Mills KL, Teeson M, Back SE, Brady KT, Baker AL, Hopwood S, Sannibale C, Barrett EL, Merz S, Rosenfeld J, Ewer PL. Integrated exposure based therapy for co-occurring post traumatic stress disorder and substance dependence: A randomized controlled trial. Journal of the American Medical Association. 2012;308(7):690–699. doi: 10.1001/jama.2012.9071. [DOI] [PubMed] [Google Scholar]
- Mills KL, Teesson M, Ross J, Peters L. Trauma, PTSD, and substance use disorders: Findings from the Australian National Survey of Mental Health and Well-Being. American Journal of Psychiatry. 2006;163(4):652–658. doi: 10.1176/appi.ajp.163.4.652. [DOI] [PubMed] [Google Scholar]
- Nace EP. Posttraumatic stress disorder and substance abuse. Clinical issues. Recent Developments in Alcoholism. 1988;6:9–26. doi: 10.1007/978-1-4615-7718-8_1. [DOI] [PubMed] [Google Scholar]
- Najavits LM. Seeking Safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press; 2002. [Google Scholar]
- Najavits LM, Gallop RJ, Weiss RD. Seeking safety therapy for adolescent girls with PTSD and substance use disorder: A randomized controlled trial. Journal of Behavioral Health Services and Research. 2006;33:453–463. doi: 10.1007/s11414-006-9034-2. [DOI] [PubMed] [Google Scholar]
- Najavits LM, Runkel R, Neuner C, Frank AF, Thase ME, Crits-Christoph P, Blaine J. Rates and symptoms of PTSD among cocaine-dependent patients. Journal of Studies on Alcohol. 2003;64:601–606. doi: 10.15288/jsa.2003.64.601. Retrieved from http://www.jsad.com. [DOI] [PubMed] [Google Scholar]
- Najavits LM, Schmitz M, Gotthardt S, Weiss RD. Seeking Safety plus Exposure Therapy: An outcome study on dual diagnosis men. Journal of Psychoactive Drugs. 2005;27:425–435. doi: 10.1080/02791072.2005.10399816. [DOI] [PubMed] [Google Scholar]
- Najavits LM, Sullivan TP, Schmitz M, Weiss RD, Lee CSN. Treatment utilization of women with PTSD and substance dependence. American Journal on Addictions. 2004;13:215–224. doi: 10.1080/10550490490459889. [DOI] [PubMed] [Google Scholar]
- Najavits LM, Weiss RD, Shaw SR, Muenz L. “Seeking safety”: Outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence. Journal of Traumatic Stress. 1998;11:437–456. doi: 10.1023/A:1024496427434. [DOI] [PubMed] [Google Scholar]
- Nacasch N, Foa EB, Huppert JD, Tzur D, Fostick L, Dinstein Y, Polliack M, Zohar J. Prolonged Exposure therapy for combat- and terror- related posttraumatic stress disorder: A randomized control comparison with treatment as usual. Journal of Clinical Psychiatry. 2011;72(9):1174–1180. doi: 10.4088/JCP.09m05682blu. [DOI] [PubMed] [Google Scholar]
- Norman SB, Tate SR, Anderson KG, Brown SA. Do trauma history and PTSD symptoms influence addiction relapse context? Drug and Alcohol Dependence. 2007;90:89–96. doi: 10.1016/j.drugalcdep.2007.03.002. [DOI] [PubMed] [Google Scholar]
- Norman SB, Wilkins KC, Tapert SF, Lang AJ, Najavits LM. A pilot study of seeking safety therapy with OEF/OIF veterans. Journal of Psychoactive Drugs. 2010;42:83–87. doi: 10.1080/02791072.2010.10399788. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ouimette PC, Ahrens C, Moos RH, Finney JW. Posttraumatic stress disorder in substance abuse patients: Relationships to 1 year posttreatment outcomes. Psychology of Addictive Behaviors. 1997;1:34–47. doi: 10.1037/0893-164X.11.1.34. [DOI] [Google Scholar]
- Ouimette PC, Brown PJ, Najavits LM. Course and treatment of patients with both substance use and posttraumatic stress disorders. Addictive Behaviors. 1998;23:785–795. doi: 10.1016/S0306-4603(98)00064-1. [DOI] [PubMed] [Google Scholar]
- Ouimette P, Goodwin E, Brown PJ. Health and well being of substance use disorder patients with and without posttraumatic stress disorder. Addictive Behaviors. 2006;31(8):1415–1423. doi: 10.1016/j.addbeh.2005.11.010. [DOI] [PubMed] [Google Scholar]
- Ouimette P, Read JP, Wade M, Tirone V. Modeling associations between posttraumatic stress symptoms and substance use. Addictive Behaviors. 2010;35:64–67. doi: 10.1016/j.addbeh.2009.08.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Petrakis IL, Poling J, Levinson C, Nich C, Carroll K, Rounsaville B. Naltrexone and disulfiram in patients with alcohol dependence and comorbid psychiatric disorders. Biol Psychiatry. 2005;57(10):1128–1137. doi: 10.1016/j.biopsych.2005.02.016. [DOI] [PubMed] [Google Scholar]
- Petrakis IL, Rosenheck R, Desai R. Substance use comorbidity among Veterans with posttraumatic stress disorder and other psychiatric illness. The American Journal on Addictions. 2011;20:185–189. doi: 10.1111/j.1521-0391.2011.00126.x. [DOI] [PubMed] [Google Scholar]
- Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders. 2011;25:456–465. doi: 10.1016/j.janxdis.2010.11.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pitman RK, Altman B, Greenwald E, Longpre RE, Macklin ML, Steketee GS. Psychiatric complications during flooding therapy for posttraumatic stress disorder. Journal of Clinical Psychiatry. 1991;52(1):17–20. Retrieved from http://www.psychiatrist.com. [PubMed] [Google Scholar]
- Powers MB, Halpern JM, Ferenschak MP, Gillihan SJ, Foa EB. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review. 2010;30:635–641. doi: 10.1016/j.cpr.2010.04.007. [DOI] [PubMed] [Google Scholar]
- Preston KL, Silverman K, Schuster CR, Cone EJ. Assessment of cocaine use with quantitative urinalysis and estimation of new uses. Addiction. 1997;92(6):717–727. doi: 10.1046/j.1360-0443.1997.9267178.x. [DOI] [PubMed] [Google Scholar]
- Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry. 2003;9:9–14. doi: http://dx.doi.org/10.1185/135525703125002360. [Google Scholar]
- Read JP, Brown PJ, Kahler CW. Substance use and posttraumatic stress disorders: Symptom interplay and effects on outcome. Addictive Behaviors. 2004;29(8):1665–1672. doi: 10.1016/j.addbeh.2004.02.061. [DOI] [PubMed] [Google Scholar]
- Reed PL, Anthony JC, Breslau N. Incidence of drug problems in young adults exposed to trauma and posttraumatic stress disorder: do early life experiences and predispositions matter? Archives of General Psychiatry. 2007;64(12):1435–1442. doi: 10.1001/archpsyc.64.12.1435. doi: http://dx.doi.org/10.1001/archpsyc.64.12.1435. [DOI] [PubMed] [Google Scholar]
- Resick PA, Williams LF, Suvak MK, Monson CM, Gradus JL. Long-term outcomes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. J Consult Clin Psychol. 2012;80(2):201–210. doi: 10.1037/a0026602. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Richter L, Johnson PB. Current methods of assessing substance use: A review of strengths, problems, & developments. Journal of Drug Issues. 2001;31(4):809–832. doi: 10.1177/002204260103100401. [DOI] [Google Scholar]
- Robins LN, Wing J, Wittchen HU, Leltzer JE, Babor TF, Burke J, Farmer A, Jablensky A, Pickens R, Regier DA, Sartorius N, Towle LH. The Composite International Diagnostic Interview: An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry. 1989;45:1069–1077. doi: 10.1001/archpsyc.1988.01800360017003. [DOI] [PubMed] [Google Scholar]
- Saladin ME, Brady KT, Dansky BS, Kilpatrick DG. Understanding comorbidity between PTSD and substance use disorder: Two preliminary investigations. Addictive Behaviors. 1995;20:643–655. doi: 10.1016/0306-4603(95)00024-7. [DOI] [PubMed] [Google Scholar]
- Saladin ME, Drobes DJ, Coffey SF, Dansjy BS, Brady KT, Kilpatrick DG. PTSD symptom severity as a predictor of cue-elicited drug craving in victims of violent crime. Addictive Behaviors. 2003;28:1611–1629. doi: 10.1016/j.addbeh.2003.08.037. [DOI] [PubMed] [Google Scholar]
- Santiago PN, Joshua E, Wilk JE, Milliken CS, Castro CA, Engel CC, Hoge CW. Screening for alcohol misuse and alcohol-related behaviors among combat veterans. Psychiatric Services. 2010;61(6):575–581. doi: 10.1176/ps.2010.61.6.575. [DOI] [PubMed] [Google Scholar]
- Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption. Addictions. 1993;88:296–303. doi: 10.1111/j.1360-0443.1993.tb02093.x. [DOI] [PubMed] [Google Scholar]
- Schnitt JM, Nocks JJ. Alcoholism treatment of Vietnam veterans with post-traumatic stress disorder. Journal of Substance Abuse Treatment. 1984;1:179–189. doi: 10.1016/0740-5472(84)90021-7. [DOI] [PubMed] [Google Scholar]
- Seal K, Bertenthal D, Miner C, Sen S, Marmar C. Bringing the war back home: Mental health disorders among 103,788 U.S. veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine. 2007;167:476–482. doi: 10.1001/archinte.167.5.476. [DOI] [PubMed] [Google Scholar]
- Selzer ML. The Michigan Alcoholism Screening Test: The test for a new diagnostic instrument. American Journal of Psychiatry. 1971;127:1653–1658. doi: 10.1176/ajp.127.12.1653. [DOI] [PubMed] [Google Scholar]
- Sharkansky EJ, Brief DJ, Peirce JM, Meehan JC, Mannix LM. Substance abuse patients with posttraumatic stress disorder (PTSD): identifying specific triggers of substance use and their associations with PTSD symptoms. Psychology of Addictive Behaviors. 1999;13:89–97. doi: 10.1037/0893-164X.13.2.89. [DOI] [Google Scholar]
- Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Herguesta T, Baker R, Dunbar GC. The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry. 1998;59:22–33. Retrieved from http://www.psychiatrist.com. [PubMed] [Google Scholar]
- Shipherd JC, Stafford J, Tanner LR. Predicting alcohol and drug abuse in Persian Gulf War veterans: what role do PTSD symptoms play? Addictive Behaviors. 2005;30(3):595–599. doi: 10.1016/j.addbeh.2004.07.004. [DOI] [PubMed] [Google Scholar]
- Simons J, Correia CJ, Carey KB, Borsari BE. Validating a five-factor marijuana motives measure: Relations with use, problems, and alcohol motives. Journal of Counseling Psychology. 1998;45:265–273. doi: 10.1037/0022-0167.45.3.265. [DOI] [Google Scholar]
- Skinner HA, Horn JL. Alcohol Dependence Scale (ADS): User guide. Toronto: Addiction Research Foundation; 1984. [Google Scholar]
- Sobell LC, Sobell MB. Alcohol Timeline Follow-back user’s manual. Toronto: Addictions Research Foundation; 1995. [Google Scholar]
- Souza T, Spates CR. Treatment of PTSD and substance abuse comorbidity. Behavior Analyst Today. 2008;9:11–26. Retrieved from http://www.baojournal.com. [Google Scholar]
- Steenkamp M, McLean CP, Arditte KA, Litz BT. Exposure to trauma in adults. In: Antony MM, Barlow DH, editors. Handbook of assessment and treatment planning for psychological disorders. 2. New York: Guilford; 2011. pp. 301–343. [Google Scholar]
- Stewart SH. Alcohol abuse in individuals exposed to trauma: A critical review. Psychological Bulletin. 1996;120:83–112. doi: 10.1037/0033-2909.120.1.83. [DOI] [PubMed] [Google Scholar]
- Stewart SH, Conrod PJ. Psychosocial models of functional associations between posttraumatic stress disorder and substance use disorder. In: Ouimette P, Brown PJ, editors. Trauma and substance abuse: Causes, consequences, and treatment of comorbid disorders. Washington, DC: American Psychological Association; 2003. pp. 29–55. [Google Scholar]
- Stewart SH, Conrod PJ. Anxiety and substance use disorders: The vicious cycle of comorbidity. New York, NY US: Springer Science; 2008. [DOI] [Google Scholar]
- Stewart SH, Conrod PJ, Samoluk SB, Pihl RO, Dongier M. Posttraumatic stress disorder symptoms and situation-specific drinking in women substance abusers. Alcoholism Treatment Quarterly. 2000;18:31–47. doi: 10.1300/J020v18n03_04. [DOI] [Google Scholar]
- Substance Abuse and Mental Health Services Administration (SAMHSA). [Accessed on April 6, 2012];National Registry of Evidence-based Programs and Practices. 2007 Available at http://www.nrepp.samhsa.gov.
- Tarrier N. Suicide risk in civilian PTSD patients: Predictors of suicidal ideation, planning and attempts. Social Psychiatry and Psychiatric Epidemiology. 2004;39:655–661. doi: 10.1007/s00127-004-0799-4. Retrieved from http://search.ebscohost.com. [DOI] [PubMed] [Google Scholar]
- Tate SR, Norman SB, McQuaid JR, Brown SA. Health problems of substance dependent veterans with and those without trauma history. Journal of Substance Abuse Treatment. 2007;33:25–32. doi: 10.1016/j.jsat.2006.11.006. [DOI] [PubMed] [Google Scholar]
- Thomas JL, Wilk JE, Riviere LA, McGurk D, Castro CA, Hoge CW. Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry. 2010;67(6):614–623. doi: 10.1001/archgenpsychiatry.2010.54. [DOI] [PubMed] [Google Scholar]
- Triffleman E. Gender differences in a controlled pilot study of psychosocial treatments in substance dependent patients with post-traumatic stress disorder: Design considerations and outcomes. Alcoholism Treatment Quarterly. 2000;18(3):113–126. doi: 10.1300/J020v18n03_10. [DOI] [Google Scholar]
- Triffleman E, Carroll K, Kellogg S. Substance dependence posttraumatic stress disorder therapy. An integrated cognitive-behavioral approach. Journal of Substance Abuse Treatment. 1999;17(1–2):3–14. doi: 10.1016/S0740-5472(98)00067-1. [DOI] [PubMed] [Google Scholar]
- Triffleman EG, Marmar CR, Delucchi KL, Ronfeldt H. Childhood trauma and posttraumatic stress disorder in substance abuse inpatients. Journal of Nervous and Mental Disease. 1995;183(3):172–176. doi: 10.1097/00005053-199503000-00008. [DOI] [PubMed] [Google Scholar]
- Tucker JA, Murphy JG, Kertesz SG. Substance use disorders. In: Antony MM, Barlow DH, editors. Handbook of assessment and treatment planning for psychological disorders. 2. New York: Guilford; 2011. pp. 529–570. [Google Scholar]
- van Dam D, Vedel E, Ehring T, Emmelkamp PMG. Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder: A systematic review. Clinical Psychology Review. 2012;32:202–214. doi: 10.1016/j.cpr.2012.01.004. [DOI] [PubMed] [Google Scholar]
- van Minnen A, Foa E. The effect of imaginal exposure length on outcome of treatment for PTSD. Journal of Traumatic Stress. 2006;19(4):427–438. doi: 10.1002/jts.20146. [DOI] [PubMed] [Google Scholar]
- Wasserman DA, Havassy BE, Boles SM. Traumatic events and post-traumatic stress disorder in cocaine users entering private treatment. Drug & Alcohol Dependence. 1997;46:1–8. doi: 10.1016/S0376-8716(97)00048-3. [DOI] [PubMed] [Google Scholar]
- Weis M. Integrated and holistic treatment approach to PTSD and SUD: A synergy. Journal of Addictions and Offender Counseling. 2010;31:25–37. doi: 10.1002/j.2161-1874.2010.tb00064.x. [DOI] [Google Scholar]
- Weiss DS, Marmar CR. The Impact of Events Scale-Revised. In: Wilson J, Keane TM, editors. Assessing psychological trauma and PTSD. New York: Guilford; 1996. pp. 399–411. [Google Scholar]
- Widdop B, Caldwell R. The operation of a hospital laboratory service for the detection of drugs of abuse. In: Gough TA, editor. The Analysis of Drugs of Abuse. England: John Wiley & Sons; 1991. pp. 429–452. [Google Scholar]
- Wolff K, Welch S, Strang J. Specific laboratory investigations for assessments and management of drug problems. Advances in Psychiatric Treatment. 1999;5:180–191. doi: 10.1192/apt.5.3.180. [DOI] [Google Scholar]
- Young HE, Rosen CS, Finney JW. A survey of PTSD screening and referral practices in VA addiction treatment programs. Journal of Substance Abuse Treatment. 2005;28(4):313–319. doi: 10.1016/j.jsat.2005.02.006. [DOI] [PubMed] [Google Scholar]
- 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. Behavior Therapy. 2009;40:325–336. doi: 10.1016/j.beth.2008.09.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Zlotnick C, Najavits LM, Rohsenow DJ, Johnson DM. A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: Findings from a pilot study. Journal of Substance Abuse Treatment. 2003;25:99–105. doi: 10.1016/S0740-5472(03)00106-5. [DOI] [PubMed] [Google Scholar]
- Zywiak WH, Connors GJ, Maisto SA, Westerberg VS. Relapse research and the Reasons for Drinking Questionnaire: a factor analysis of Marlatt’s relapse taxonomy. Addiction. 1996;91:S121–S130. doi: 10.1080/09652149638854. [DOI] [PubMed] [Google Scholar]