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. Author manuscript; available in PMC: 2024 Mar 1.
Published in final edited form as: J Trauma Dissociation. 2022 Oct 20;24(2):229–240. doi: 10.1080/15299732.2022.2136327

Women with PTSD and Substance Use Disorders in a Research Treatment Study: A Comparison of Those with and Without the Dissociative Subtype of PTSD

Therese K Killeen 1, Timothy D Brewerton 1,2
PMCID: PMC9905299  NIHMSID: NIHMS1857339  PMID: 36266949

Abstract

Significant differences in clinical features have been reported in women with substance use disorders (SUDs) between those with the dissociative subtype of posttraumatic stress disorder (D-PTSD) compared to those without, namely more severe trauma histories, PTSD symptoms, and general psychopathology. This presentation reports on a group of 88 women with PTSD and SUD taking part in a research treatment study. All women were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and were categorized into those with (n = 23, 26%) and without (n = 65, 74%) D-PTSD. Assessments for SUDs were via the Multi International Neuropsychiatric Inventory, Seventh Version (MINI-7). Compared to those without D-PTSD, those with D-PTSD had significantly higher CAPS-5 scores (50.5 ± 9.9 v. 39.6 ± 8.8), greater number of PTSD symptoms (16.4 ± 2.6 v. 14.2 ± 2.4), more alcohol use disorder (AUD) (65.2% v. 30.8%) and more non-cocaine stimulant use disorder (34.8% v. 12.3%). No significant differences were found for other SUDs. These women with SUDs and D-PTSD have higher degrees of PTSD severity as well as unique clinical presentations. Future research is needed to explore the significance of these findings for clinical assessment and treatment.

Keywords: PTSD, dissociation, dissociative subtype of PTSD, substance use disorders, women, mindfulness, emotion dysregulation

Introduction

The publication of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) heralded a new and distinct subtype of posttraumatic stress disorder (PTSD) called the dissociative subtype of PTSD (D-PTSD) (American_Psychiatric_Association, 2013). D-PTSD is characterized by the presence of depersonalization, which involves the persistent or recurrent experiences of feeling detached from oneself, and by derealization, which involves persistent or recurrent experiences of unreality of surroundings. Very importantly for this population, these experiences are not due to alcohol, drugs or medical conditions. In the recent past, convincing evidence has surfaced that D-PTSD exemplifies a clinical population with unique epidemiological and neurobiological features (Lanius et al., 2010; Stein et al., 2013). The prevalence estimates of D-PTSD in patients with PTSD have been reported to range from 6% to 44.6% (Hansen et al., 2017; Schiavone et al., 2018). One systematic review of the literature estimated the mean prevalence to be 20.4% (Hansen et al., 2017). These authors noted that the existing database is heterogeneous with regard to risk factors and accompanying features of D-PTSD, which is possibly due to diverse populations and different working definitions of D-PTSD. However, they noted its association with a history of exposure to childhood trauma as well as the co-occurrence of other forms of psychopathology, such as depression and anxiety. A recent more inclusive meta-analysis with a broader definition of D-PTSD found a prevalence rate of 38% (White et al., 2022). The authors also note a high degree of heterogeneity in the studies making it difficult to identify moderators. Taken together, the D-PTSD phenotype has been associated with greater complexity and chronicity of both trauma history and overall burden of illness.

The prevalence and severity of PTSD in women is two to three times higher than in men (Olff, 2017). In one study, peritraumatic fear, horror, and helplessness and negative posttraumatic cognitions about self and the world were unique risk factors that accounted for the gender differences in PTSD (Christiansen & Hansen, 2015). More emotion focused coping in women has been suggested to predict the development of PTSD following trauma (Hu et al., 2017). Complex PTSD, as defined in the International Classification of Disease 11th edition (ICD 11), is associated with additional clinical features of emotional dysregulation, negative self-cognitions and interpersonal hardship (Giourou et al., 2018). Studies have also found that complex trauma, PTSD and dissociation are more prevalent in females with a history of childhood abuse history (Banyard et al., 2001; Hetzel-Riggin & Roby, 2013; Hu et al., 2017; Najavits & Walsh, 2012; Olff, 2017; Wamser-Nanney & Cherry, 2018).

PTSD is a common comorbidity with substance use disorders (SUDs) carrying a more significant clinical burden than either disorder presenting alone (Gielen et al., 2012; McCauley et al., 2012; Torchalla & Nosen, 2019). Similar to PTSD alone, previous studies in individuals with PTSD-SUD have demonstrated significant differences between those with D-PTSD compared to those without, including the identification of more severe trauma histories, PTSD symptom severity, and other measures of general psychopathology in the D-PTSD group (Mergler et al., 2017). For example, in a study with 285 women with PTSD-SUD, the 18.7% who met DSM-5 criteria for D-PTSD showed greater PTSD and drug use severity, greater histories of childhood emotional abuse, sexual abuse, and emotional neglect, more symptoms of depression, more symptoms of borderline personality disorder, and more suicidal thoughts and attempts (Gidzgier et al., 2019). Individuals with D-PTSD and SUD also have a significantly higher need for treatment due to drug problems, higher current use of opiates/analgesics, and a higher number of lifetime drug overdoses (Mergler et al., 2017).

This report is a secondary analysis from a randomized control trial (RCT) of a group of 88 women with SUD-PTSD. The study differs from previous studies in that participants were treatment seeking women enrolled in community intensive SUD treatment, representing a more symptomatic group. Women represent a vulnerable and under-representative population in SUD treatment with various needs that are typically addressed in gender specific groups (McHugh et al., 2018).

We hypothesized that we would find a substantial minority of patients with D-PTSD who would show greater severity on a number of clinical, substance use and trauma-related measures. In addition, we hypothesized that this subgroup would likely score lower on measures of mindfulness and higher on measures of emotion dysregulation. Given dissociation has been linked to complex PTSD, exploring differences in emotional dysregulation and mindfulness would be informative in identifying treatment targets for this complex comorbid population (Hyland et al., 2020).

Methods

Participants:

The current study used baseline data from a large randomized control trial exploring the efficacy of integrated interventions for PTSD and SUD in a sample of women enrolled in community substance use disorder treatment (Vrana et al., 2017). All women were enrolled in community intensive treatment programs between ages 18 and 65 who met criteria for current DSM-5 PTSD with Clinician Administered PTSD Scale for DSM-5 (CAPS-5) scores of ≥ 25 (Weathers et al., 2018) (Weathers, personal communication). In addition, all participants met criteria for current DSM-5 alcohol and/or substance use disorder and endorsed use of alcohol/substances within 60 days prior to program admission. If women were on any psychotropic medications, they had to be stabilized for at least 4 weeks. Anyone with significant homicidal, psychotic or suicidal behavior were excluded.

Ethics.

This research was approved by the University Institutional Review Board associated with the study. The study was located in an urban community SUD treatment program in the Southeast US which partially serves areas outside the city. Services provided include medical and clinical detoxification, inpatient, outpatient and intensive outpatient programs, medication (methadone/suboxone) for opioid use disorder (MOUD) clinic and a women’s residential program that allows women to bring children under the age of five. The women’s residential and intensive outpatient program (WIOP) accepts referrals throughout the state. Women were mostly self- referred or mandated to treatment by child protective services. The proposed study recruited from the (WIOP). The WIOP provides groups and classes focused on psychoeducation, relapse prevention, 12-step and parenting up to 20 hours/ four days a week and last approximately 10 weeks. The program also includes a weekly integrated coping skills (ICS) group intervention that addresses both trauma and substance related triggers. The study intervention is a mindfulness-based relapse prevention (MBRP) group. In the randomized control study, the MBRP replaced the ICS group for those randomized to MBRP.

Upon admission to the WIOP, women were referred by the clinical SUD admission counselor or assigned SUD clinical counselor to be pre-screened for interest and preliminary eligibility to participate in the research study. Due to reporting responsibilities women who were pregnant or planning to become pregnant during the study were excluded from study participation and continued their WIOP. Prior to initiation of any assessments or study procedures, women signed an informed consent to participate in the study. Women not interested or ineligible continued their intensive community program as usual. Women were also informed that if at any time during the study they decided to drop out they would remain enrolled in their standard treatment program. Eligible and interested women were enrolled and randomized within 1-2 weeks into the clinical SUD treatment program.

Assessments:

All women enrolled in the study were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and were categorized into those with and without D-PTSD (Weathers et al., 2018). Assessments for SUDs were via the Multi International Neuropsychiatric Inventory, Seventh Version (MINI-7) (Sheehan et al., 1998). Measures of mindfulness and emotion regulation were also administered, including the Mindfulness Awareness and Attention Scale (MAAS) (Brown & Ryan, 2003), the Difficulty in Emotion Regulation Scale (DERS) (Gratz & Roemer, 2004). Participants received $35 for the screening assessment and $20 for the baseline assessment.

Study Design:

This report is part of a larger National Institute of Drug Abuse (NIDA) randomized study exploring an adapted version of Mindfulness Based Relapse Prevention (MBRP) plus treatment as usual (TAU) or TAU plus ICS group for women with comorbid PTSD and SUD (PTSD-SUD) (Vrana et al., 2017). Interested women enrolled in a community-based SUD treatment program who met eligibility criteria were randomly assigned to either the adapted MBRP plus TAU or an ICS group plus TAU. Participants with D-PTSD were compared to those without D-PTSD on baseline measures.

Statistics:

Patients with and without D-PTSD were compared on a number of demographic and clinical parameters using independent sample t-test (two-tailed) for parametric data or chi-square analyses for nonparametric data. Comparisons between groups on baseline measures of PTSD symptoms severity, emotional dysregulation and mindfulness were performed by using one-way multivariate analysis of variance. Homogeneity of covariances for group comparisons were tested using the Box M statistic. Partial eta squared (η2) values are reported to estimate the effect size of the proportion of variance explained by a given variable after accounting for variance explained by other variables in the model.

Results

The demographic and psychosocial history of the participants by PTSD subtype is shown in Table 1. Twenty-three of the 88 participants (26%) met criteria for D-PTSD, while 55 did not (74%). There were no significant differences between the D-PTSD and non-D-PTSD groups for age, race, education, or marital status. There was a trend for a higher percentage of women with D-PTSD to not be living with their biological children under the age of 18 years.

Table 1.

Demographic and psychosocial history in total group and by posttraumatic stress disorder (PTSD) subtype.

Total (n=88) PTSD (n=65) D-PTSD (n=23) Statistic df p-value
Age (mean ± SD years) 32.16 (7.8) 32.2 (7.8) 32 (8.1) t = 0.113 86 .9
Race (n, %)
 White 58 (65.9%) 43 (66.2%) 15 (65.3%) χ2 = 0.14 2 .9
 African American 21 (23.9%) 15 (23.1%) 6 (26.1%)
 Other 9 (10.2%) 7 (10.8%) 2 (2.3%)
Education (mean ± SD years) 12.45 (2.0) 12.5 (2.0) 12.35 (2.0) t = 0.295 86 .77
Employed (n, %)
 Full time 7 (8.0%) 5 (7.7%) 2 (8.7%) χ2 = 6.97 4 .14
 Part time 13 (14.8%) 7 (10.8%) 6 (26.1%)
 Unemployed 63 (71.6%) 50 (76.9%) 13 (56.5%)
 Student 2 (2.3%) 2 (3.1%) 0 (0%)
 Disabled 3 (3.4%) 1 (1.5%) 2 (8.7%)
Marital Status (n, %)
  Single/Never Married 47 (53.4%) 34 (52.3%) 13 (56.5%) χ2 = 4.2 2 .38
  Married 13 (14.8%) 12 (18.5%) 1 (4.3%)
  Separated/Divorced/Widow 28 (31.8%) 19 (29.2%) 9 (39.1%)
Not living with biological children <18 yrs (n, %) 52 (59.1%) 35 (53.8%) 17 (73.9%) χ2 = 2.83 1 .09
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PTSD = PTSD (non-dissociative); D-PTSD = dissociative subtype of PTSD.

A comparison of co-morbid diagnoses and other clinical features between the two groups is shown in Table 2. Notably, significantly higher rates of several comorbid diagnoses were seen in the D-PTSD group, including major depressive disorder, bipolar disorder, panic disorder, generalized anxiety disorder, and agoraphobia. Significantly more individuals with D-PTSD met criteria for alcohol use disorder (AUD) and methamphetamine/stimulant use disorder than those without D-PTSD. In addition, significantly more individuals with D-PTSD were being treated with psychotropic medications.

Table 2.

Lifetime mental health and substance use disorder history by posttraumatic stress disorder (PTSD) subtype.

Total (n=88) PTSD (n=65) D-PTSD (n=23) Statistic df p-value
Suicide attempts (current and past) (n, %) 51 (58.0%) 34 (52.3%) 17 (73.9%) χ2 = 3.25 1 .07
Comorbid Psychiatric Diagnosis (n, %)
 Major Depressive Disorder 44 (50.0%) 37 (56.9%) 7 (30.4%) χ2 = 4.77 1 .03
 Bipolar Disorder 25 (28.4%) 12 (18.5%) 13 (56.5%) χ2 = 12.1 1 .001
 Panic 31 (35.2%) 19 (29.2%) 12 (52.2%) χ2 = 3.92 1 .05
 General anxiety 42 (47.7%) 25 (38.5%) 17 (73.9%) χ2 = 8.56 1 .003
 Agoraphobia 33 (37.5%) 25 (38.5%) 14 (61%) χ2 = 7.26 1 .007
Child Abuse (n, %) 39 (44.3%) 30 (46.2%) 9 (39.1%) χ2 = 0.34 1 .63
  Sexual 34 (38.6%) 25 (38.5%) 9 (39.1%) χ2 = 0.003 1 .96
  Physical 5 (5.7%) 5 (7.7%) 0 (0%) χ2 = 1.88 1 .32
  Physical + Sexual 10 (11.4%) 7 (10.8%) 3 (13.0%) χ2 = 0.87 1 .72
Psychotropic Medications (n, %) 52 (59.1%) 33 (50.8%) 19 (82.6%) χ2 = 7.12 1 .013
SUD Diagnoses (n, %)
 Opioids 38 (43.2%) 31 (47.7%) 7 (30.4%) χ2 = 2.06 1 .2
 Marijuana 30 (34.1%) 23 (35.4%) (30.4%) χ2 = 0.19 1 .7
 Alcohol 35 (39.8%) 20 (30.8%) 15 (65.2%) χ2 = 8.42 1 .004
 Cocaine 22 (25.0%) 16 (24.6%) 6 (26.1%) χ2 = 0.02 1 .89
  Methamphetamine/Stimulants 16 (18.2%) 8 (12.3) 8 (34.8%) χ2 = 5.77 1 .02
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PTSD = PTSD (non-dissociative). D-PTSD = dissociative subtype of PTSD.

Table 3 displays a comparison of total CAPS-5 scores, cluster PTSD scores, total number of PTSD symptoms, and the mindfulness (MAAS) and emotion regulation (DERS) scores. The D-PTSD group had significantly higher total CAPS-5 scores including cluster B (intrusion/re-experiencing symptoms), cluster C (avoidance symptoms), cluster D (alterations in cognition and mood symptoms) and cluster E (arousal/hypervigilance symptoms), and total number of PTSD symptoms than those without D-PTSD. In addition, the D-PTSD group had significantly higher scores on the MAAS and the DERS.

Table 3.

A comparison of posttraumatic stress disorder (PTSD) symptom severity, mindfulness and emotional regulation measures in PTSD subtype (mean ± SD).

PTSD (n=65) D-PTSD (n=23) F stat df p-value Partial eta squared
CAPS-5
 Total Score 39.6 (8.8) 50.5 (9.9) 24.1 86 <.001 0.22
  Cluster B (Intrusion) 10.3 (3.3) 13.1 (3.6) −3.34 86 <.001
  Cluster C (Avoidance) 5.0 (1.7) 6.4 (1.6) −3.53 86 <.001
  Cluster D (Cognitions/mood) 14.1 (4.2) 17.1 (4.0) −3.03 86 <.003
  Cluster E (Hypervigilance) 10.2 (3.7) 13.8 (2.9) −4.28 86 <.001
Total Number of Symptoms 14.2 (2.4) 16.4 (2.6) −3.58 86 <.001 −0.86
MAAS 3.5 (1.1) 2.9 (1.1) 5.87 86 .017 0.04
DERS 100.9 (30.2) 116 (25.9) 4.58 86 .035 0.5
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PTSD = PTSD (non-dissociative); D-PTSD = dissociative subtype of PTSD.

CAPS-5 = Clinician Administered PTSD Scale for DSM-5; MAAS = Mindfulness Awareness and Attention Scale; DERS = Difficulty in Emotion Regulation Scale

Discussion

The current study explored clinical differences between PTSD and D-PTSD in a sample of women with comorbid PTSD and SUD receiving intensive outpatient treatment for SUD. Our results add to the current literature documenting that women with SUD-PTSD who have D-PTSD have higher PTSD symptom severity, more psychiatric comorbidity, and more severe psychosocial problems than women with SUD-PTSD who do not meet criteria for D-PTSD. In non-SUD populations there are more mixed results when exploring clinical differences between the PTSD subtypes (Hill et al., 2020). Alternatively, the few studies exploring D-PTSD in SUD populations show greater PTSD severity (Gidzgier et al., 2019; Mergler et al., 2017). In a recent study of 344 individuals seeking treatment for PTSD, dissociation mediated the relationship between PTSD symptom severity and alcohol related problems (Patel et al., 2022). Greater PTSD severity was associated with dissociative symptoms which in turn was associated with greater alcohol related problems. This was specifically true for the three cluster symptoms of intrusion, negative affect and cognitions and reactivity. In the current study over twice as many women in the D-PTSD group had an AUD than in the PTSD group. More use of psychotropic medicine in the D-PTSD group most likely reflects more affective and anxiety disorders seen in the D-PTSD group. Depression, anxiety, suicide thoughts and attempts, and borderline personality have also been reported to co-occur with D-PTSD (Gidzgier et al., 2019; Mergler et al., 2017). The current study found a trend for women in the D-PTSD to have more lifetime and current suicide attempts than those women in the PTSD without dissociative features. Unlike other studies, child abuse (sexual and physical) did not differ between the subtype groups. This could be due to the small sample size as well as a ceiling effect in that almost half of the women in the sample reporting child abuse.

Our results also demonstrate that significant difficulties with emotion regulation and lower mindfulness differentiate D-PTSD from PTSD without dissociation. Deficits in emotion regulation in individuals with SUD and other stress related disorders, including PTSD, are reported to be associated with increased symptom severity as well as treatment attrition and recovery relapse (Berking et al., 2011; Gilmore et al., 2020).

In a meta-analysis on the relationship between dissociation and emotional regulation, Cavicchiola and colleagues found moderate to large effect sizes showing that dissociation was associated with maladaptive domains of emotional regulation, including disengagement (behavioral and experiential avoidance, emotional and thought suppression) and aversive cognitive perseveration (rumination, worry, nonacceptance) (Cavicchioli et al., 2021). Emotional regulation skills may be a particularly important component of treatment for individuals with D-PTSD. In another study bodily dissociation and emotional regulation difficulties were shown to mediate post-traumatic stress (PTS) symptom severity among women with SUD. Improvement in awareness and acceptance of sensory cues reduced emotional escalation and reactivity and improved PTSD symptom severity (Price & Herting, 2013). It has also been shown that the link between mindfulness and dissociation may be mediated by attention and emotional acceptance (Vancappel et al., 2021)

There are limited number of evidence-based interventions that target both PTSD and SUD that can be delivered in a community SUD treatment program. Clinicians have only recently started assessing and treating PTSD-SUD with the most common treatments being psychoeducation related to PTSD and SUD and coping skills training for both PTSD and SUD related triggers (Hien et al., 2020). Despite the complex and more severe co-occurring psychosocial problems associated with D-PTSD subtype, few programs assess for dissociative symptoms or explore differences in treatment response. Although DSM-5 (APA, 2013) now includes D-PTSD, previous PTSD diagnostic criteria focused on undermodulation of trauma-related emotions and emphasized reexperiencing and hyperarousal symptoms, e.g., hypervigilance and exaggerated startle (Lanius et al., 2010). D-PTSD captures individuals who also respond to traumatic stimuli with dissociative symptoms (depersonalization or derealization) and accompanying emotional detachment. This is in addition to dissociative flashbacks and dissociative amnesia (for traumatic events), the two dissociative symptoms included in the principal diagnostic criteria for PTSD.

Limitations to the current study include the small sample size and multiple comparisons. However, the sample was inclusive of a diverse community representative population of women with various substances of abuse. In addition, use of well validated interview assessment measures were used for diagnosis of PTSD, dissociative features and AUD/SUD.

This study details a number of clinical differences in the PTSD subtypes with and without dissociative features that warrant assessment and attention. Future research should explore treatments that may benefit individuals with the dissociative type of PTSD.

Acknowledgements:

1) Presented as a paper presentation at the International Society for the Study of Trauma and Dissociation ISSTD 39th Annual virtual Conference, April 11, 2021.

2) Funding for this study was provided by NIDA Grant R01DA040968. ClinicalTrials.gov # NCT02755103

Footnotes

Data Availability Statement: The data that support the findings of this study are available on request from the first author, TKK. The data are not publicly available due to their containing information that could compromise the privacy of research participants.

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