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Untreated Symptoms of PTSD Among Cocaine-Dependent Individuals
Journal of Substance Abuse Treatment, Vol. 15, No. 6, pp. 499–504, 1998 Copyright © 1998 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/98 $19.00 1 .00
PII S0740-5472(97)00293-6
ARTICLE
Untreated Symptoms of PTSD Among Cocaine-Dependent Individuals Changes Over Time
Bonnie S. Dansky, phd, Kathleen T. Brady, md, phd, and Michael E. Saladin, phd Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Center for Drug and Alcohol Programs, Charleston, SC
Abstract – Changes over time in posttraumatic stress disorder (PTSD) symptoms during periods when individuals with substance use disorders remain abstinent has not received much attention. PTSD symptomatology over a 36-month period was studied in cocaine-dependent individuals (N 5 34) who entered a pharmacologic trial targeting cocaine use and depression, but did not include any treatment for PTSD. All participants reported at least one PTSD Criterion A event, and 17.6% had current PTSD at baseline (Base PTSD1). Significant improvements in PTSD symptoms were observed on global measures of PTSD, but not on the Impact of Events Intrusion subscale. Significant improvement in drug use severity also was observed. Compared with participants who were negative for PTSD at baseline, Base PTSD1 participants were significantly more likely to: (a) meet criteria for current PTSD at follow-up and (b) have been re-victimized over the time period of the study. Careful evaluation of intrusive symptoms may be particularly important when diagnosing PTSD in individuals with SUDs, and repeated assessment of traumatic experiences may be necessary in longitudinal studies. © 1998 Elsevier Science Inc. Keywords – posttraumatic stress disorder; substance use disorder; assessment, revictimization.
INTRODUCTION
have demonstrated that substance use disorders (SUDs) are more prevalent in individuals with a history of criminal victimization and/or PTSD than in people who are negative for such a history. Similarly, high rates of victimization and PTSD have been observed in persons with SUDs sampled from the general population and treatment facilities (e.g., Brown & Wolfe, 1994; Cottler et al., 1992; Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995; Grice, Brady, Dustan, Malcolm, & Kilpatrick, 1995; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Although researchers have documented a high rate of PTSD in individuals with SUDs, changes over time in PTSD symptoms during abstinent periods as opposed to periods of active use in persons with comorbid SUDs have not received much, if any, attention. Several researchers have observed that symptoms of depression and anxiety may be exaggerated during early recovery from alcohol
OVER THE PAST 10 years numerous national and community-based studies have documented a high co-occurrence of posttraumatic stress disorder (PTSD), victimization, and substance use disorders (Burnam et al., 1988; Cottler, Compton, Mager, Spitznagel, & Janca, 1992; Helzer, 1984; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Kulka et al., 1990). Epidemiologic studies
This project was supported by National Institute on Drug Abuse (NIDA) Grant No. DA07761 awarded to Kathleen T. Brady, MD, PhD. Requests for reprints should be addressed to Bonnie S. Dansky, PhD, Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Center for Drug and Alcohol Programs, 171 Ashley Avenue Charleston, SC 29425-0742. E-mail: bonnie dansky @smtpw.musc.edu
Received July 18, 1997; Accepted November 3, 1997.
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and dissipate with time in abstinence alone (Bowen, Cipywnyk, D’Arcy, & Keegen, 1984; Brown et al., 1995; Gawin & Kleber, 1986; Halikas et al. 1981; Mullaney & Trippett, 1979; Satel et al., 1991; Schuckit & Monteiro, 1988; Schuckit, Irwin, Howard, & Smith, 1988; Small, Stockwell, Canter & Hodgon, 1984; Thevos, Johnston, Latham, Randall, & Malcolm, 1991; Weddington, et al., 1990). Similarly, there is empirical evidence suggesting that withdrawal from drugs of abuse, such as cocaine and alcohol, can produce high levels of anxiety, and therefore, assessments conducted during periods of active use or early withdrawal may lead to inflated estimates of anxiety disorders (Bowen et al., 1984; Halikas et al., 1981; Mullaney & Trippett, 1979; Satel et al., 1991; Schuckit & Monteiro, 1988; Schuckit et al., 1988; Small et al., 1984; Weddington et al., 1990). As a result of studies suggesting an increase in anxiety during early drug and alcohol withdrawal, it has been suggested that diagnosis of most anxiety and affective disorders not be made during early recovery. This issue has not been addressed for PTSD, however, and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) provides no guidance concerning diagnosis of this disorder during periods of active use and early recovery. It is clear that symptoms of hyperarousal may be exaggerated during withdrawal periods. Activation of the locus coerulus is a part of withdrawal syndromes and has been implicated in PTSD symptoms (Kosten & Krystal, 1988). Moreover, it is possible that symptoms of avoidance may be caused by drug-using lifestyle, wherein avoidance of persons, places, and activities can occur for reasons associated with drug procurement and use. Furthermore, a behavioral theory of addiction (Stasiewicz & Maisto, 1993) suggests that individuals experiencing psychological distress seek drugs to self-medicate and dampen their emotional symptoms, which would result in an initial exacerbation of psychological symptomatology when the drug is removed. In order to clarify the course of untreated PTSD symptoms over time in patients with cocaine dependence, in-depth trauma and PTSD evaluations were conducted in a sample of cocaine dependent individuals at the time of entry into a pharmacologic trial and a the 3-month follow-up point. MATERIALS AND METHODS Subjects Participants were 34 individuals, out of a total of 93, who participated in an outpatient pharmacologic treatment trial of carbamazepine for the treatment of cocaine dependence, underwent a thorough trauma screening at baseline, and were located for a 3-month follow-up appointment. All participants met criteria for cocaine dependence, and individuals with psychotic disorders or who were cognitively impaired were excluded from
study participation. Participants were not encouraged or dissuaded from involvement in standard substance abuse interventions that were available at the institution and/or in the community (group treatment, self-help, etc.). However, none of the participants received treatment specifically designed to alleviate symptoms of PTSD. There were 20 men and 14 women in the sample, with a mean age of 32.0 (SD 5 5.5) at baseline. The sample was almost evenly split between African American (52.9%) and Caucasian (47.1%), with no other minorities, which is typical of small cities on the Southeastern seaboard. A majority of the participants completed high school/trade school (44.0%) or attended some college (32.4%), although a significant minority had dropped out of high school (23.5%). Most of the participants were unemployed (52.9%), and 53.6% had a yearly family income below $15,000. Another 8.8% had an income between $15,000 and $25,000, and the remaining participants (17.6%) reported an income above $25,000. Chi-square statistics were calculated to compare participants who were in the follow-up sample with those in the original sample who were not located for follow-up (nonparticipants). No significant differences were observed for gender, race, educational status, employment status, socioeconomic status, or the prevalence of current PTSD (17.6% for the participants vs. 24.6% for nonparticipants, x2[1] 5 0.59, p 5 .44). Instruments Substance Use and Psychiatric Assessment. Substance use disorders were evaluated using the Addiction Severity Index (ASI; McClellan, Parikh, & Bragg, 1990), a modified version of the Time Line Follow-Back (Sobell & Sobell, 1978), and urine drug screen. The Structured Clinical Interview for DSM-III-R (SCID-R; Spitzer, Williams, & Gibbon, 1987) was used to ascertain the diagnosis of cocaine dependence and psychiatric disorders. Trauma and PTSD Assessment. A history of traumatic events was evaluated at baseline (study entry) using Part I of the National Women’s Study PTSD Module (NWS; Kilpatrick, Resnick, Saunders, & Best, 1989), which includes behaviorally specific questions about sexual assault, physical assault, witnessing homicide, natural disaster, combat, serious/life-threatening accidents, and any other life-threatening events (see Dansky et al. 1995; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993 for details). Part II of the NWS was used to evaluate symptoms of PTSD, in accordance with Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) criteria. Patients were classified as meeting current PTSD if they met diagnostic criteria within 6 months of the interview. Self-Report Assessment. The following self-report measures were used to evaluate PTSD: (a) Modified PTSD
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Symptom Scale-Self Report (MPSS-SR; Falsetti, Resick, Resnick, & Kilpatrick, 1992; Falsetti, Resnick, Resick, & Kilpatrick, 1993) is a modified version of the PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993) that includes 21 items designed to assess symptoms of PTSD, including their frequency and intensity; (b) Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) is a 15-item self-report scale designed to measure the extent to which a given stressful life event produces subjective distress; and (c) Symptom Check List 90-Revised (SCL-90-R; Derogatis, 1977, 1983) is a 90-item self-report symptom inventory designed to reflect psychological symptom patterns and has an empirically derived subscale to measure PTSD (Saunders, Arata, & Kilpatrick, 1990). Procedure Participants were interviewed and completed self-report questionnaires upon study entry and again at a follow-up that occurred 3 months after the 12-week study was finished. The interviewer received in-depth training on all diagnostic instruments and remained blind to the study conditions. Self-report assessments of trauma-related symptoms were administered to all participants who indicated that they had experienced at least one traumatic event during their life. RESULTS Based on the results of the NWS interview, the prevalence rate of current PTSD was 17.6% at baseline (Base PTSD1). Therefore, the “Base PTSD2” group comprised 82.4% of the sample. Of the total sample, 11.5% met criteria for current PTSD at follow-up. Forty percent of the participants who met criteria for current PTSD at baseline continued to meet criteria at the follow-up, compared with 4.8% who had not met criteria at baseline but did so at follow-up. At baseline, participants reported a
FIGURE 1. Frequency of traumatic events.
high number of traumatic experiences (see Figure 1). All 34 participants reported at least one event that met the specifications for PTSD Criterion A (DSM-III-R). Since virtually all participants in the study experienced a traumatic event, changes in self-report scores on PTSD measures were examined using the entire sample (see Figure 2). Paired sample t-tests were calculated between MPSS, SCL-90-R PTSD, IES Intrusion, and IES Avoidance scores at baseline and follow-up. There were significant improvement in scores over time on the MPSS, t(17) 5 4.71, p , .001, and SCL-90-R PTSD subscale, t(18) 5 3.48, p , .005. There was marginally significant improvement over time obtained on the IES Avoidance subscale, t(21) 5 2.01, p , .06, but no significant improvement was observed for scores on the IES Intrusion subscale. A Fisher’s Exact Test was calculated to compare the rate of new traumatic events among participants who were in the Base PTSD1 and Base PTSD2 groups. The proportion of new traumatic events was significantly higher among the participants in the Base PTSD1 group (83.3%) as compared with those in the Base PTSD2 group (35.7%; Fisher’s Exact Test 5 0.046). In order to ascertain whether the self-report scores at follow-up were influenced by any new traumatic experiences that occurred while the participant was in the study or during the follow-up period, changes in self-reported PTSD scores were examined in participants who had experienced a new trauma (n 5 11) and those who had not (n 5 7). There were no significant group differences regarding the extent of change over time on the MPSS, SCL-90-R PTSD subscale, IES Intrusion subscale, and IES Avoidance subscale. Therefore, the changes observed on these measures likely do not simply reflect participants’ new traumatic experiences. In order to determine whether the differences in PTSD symptoms as measured by the self-report instruments resulted from the pharmacologic intervention, comparisons were made between participants who received carbamazepine (n 5 17) and those in the placebo control group (n 5 17). No differences between participants in the drug and control groups were observed in the prevalence of current PTSD at baseline (17.6% drug vs. 17.6% control) or at follow-up (15.4% drug vs. 7.7% control). Similarly, comparisons calculated to compare drug and control group self-report scores did not reveal any significant differences on any of the PTSD measures. Therefore, the changes in untreated PTSD symptoms did not appear to have been influenced by the drug condition in which the participants were assigned. Comparisons (t-tests) were made between scores on the ASI at baseline and at follow-up to determine whether the changes in PTSD observed were accompanied by changes on a multidimensional measure of addiction severity (see Figure 3). For the entire sample there were significant improvements on the ASI Drug, t(25) 5 10.02, p , .00, and Family, t(24) 5 2.53, p ,
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FIGURE 2. Changes in self-reported posttraumatic stress disorder (PTSD) symptoms from baseline to follow-up. h, Baseline; j, follow-up. * p , .05; † p , .06.
.02, subscales at the follow-up assessment. In addition, participants in the Base PTSD1 group scored significantly higher at follow-up for the Legal subscale of the ASI than participants in the Base PTSD2 group, t(24) 5 2.74, p , .015. No other group differences on ASI subscale scores at follow-up were observed. DISCUSSION The topic of diagnosis and symptom profile of PTSD in the face of substance use disorders is understudied. In order to examine the extent of change in untreated symptoms of PTSD in cocaine-dependent individuals, trauma and PTSD interviews were conducted at baseline and at the 3-month follow-up, with a sample of participants in a pharmacologic trial of carbamazepine for cocaine dependence. Significant improvements in PTSD symptoms were observed on global measures of PTSD, and marginally
FIGURE 3. Changes from baseline to 36-week follow-up for Addiction Severity Index (ASI) subscale scores. h, Baseline; j, follow-up. * p , .05.
significant improvement was found for symptoms of avoidance on the IES. However, no significant improvement was evidenced on the IES Intrusion subscale. Significant improvement on a measure of addiction severity was observed for the Drug and Family subscales, and participants with current PTSD at baseline experienced less improvement at follow-up with regard to legal matters than participants negative for current PTSD at baseline. The finding of improvement over time on global measures of PTSD symptomatology, as participants also experienced decreases in drug use severity, is consistent with studies of other anxiety and affective disorders and drug abstinence/withdrawal (Thevos et al., 1991). Thevos and colleagues (1991) found that Hamilton Anxiety scores decreased by approximately 30% during a 3-week period in a group of alcoholics in early recovery. Furthermore, Brown and colleagues (1995) noted 3 weeks of abstinence from alcohol was necessary in order to make an accurate diagnosis of depression, since in primary alcoholics symptoms of depression often resolve following the detoxification process. Of interest in this study was the finding that the decrease in PTSD symptoms was not uniform across symptom clusters. Symptoms of intrusion, such as flashbacks, intrusive thoughts, and nightmares, were the most persistent over time. It is possible that intrusive symptoms that are more specific to PTSD and the traumatic event involved are less influenced by cocaine intoxication or withdrawal, and therefore, are less likely to change as a result of participation in a study addressing cocaine dependence alone. Other studies have demonstrated that symptoms of intrusion were the least likely of the PTSD symptom clusters to be influenced by substance use (Saladin, Brady, Dansky, & Kilpatrick, 1995). Many of the avoidance and hyperarousal symptoms of PTSD, such as avoidance of others, feeling detached from others, emotional numbing, irritability, and sleep disturbance, could be exacerbated or even created temporarily by early cocaine withdrawal. This would lead to higher levels of symptom endorsement of these two symptom clusters at the baseline evaluation as compared to the follow-up. In contrast, it is likely that there is much less symptom overlap between symptoms of cocaine withdrawal and symptoms of intrusion. Thus, the level of symptom endorsement for intrusions remains more stable from baseline to follow-up. Another possibility is that PTSD intrusive symptoms are more steadfast and less likely to change without the use of treatment interventions specifically designed to treat PTSD. Careful evaluation of intrusive symptoms may be particularly important when diagnosing PTSD in individuals with SUDs. The finding that the prevalence of new traumatic events was significantly higher in participants with PTSD at baseline than those without PTSD is noteworthy. This constitutes further evidence to support the observation that having PTSD is a risk factor for revictimization (Briere & Runtz, 1987; Wolfe & Kimerling,
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1997). The finding also indicates how important it is to repeatedly evaluate trauma history with participants in a longitudinal study, since a substantial proportion of them will experience new traumas while enrolled. The current study was limited in scope, given the small sample and the fact that all participants were cocaine dependent with no dependence on any other drugs. In addition, only a small proportion of the initial sample was located for follow-up, although the nonparticipants did not appear to differ from participants on important demographic and diagnostic variables. Future studies concerning changes in untreated PTSD in patients with substance use disorders should: include individuals with dependence on other drugs, which may differentially influence PTSD symptomatology; follow patients for a longer period of time; and carefully measure the exact nature of the standard substance treatment and of substance use during the evaluation period.
REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., Rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author. Bowen, R.C., Cipywnyk, D., D’Arcy, C., & Keegan, D. (1984). Alcoholism, anxiety disorders, and agoraphobia. Alcoholism: Clinical and Experimental Research, 8, 48–50. Briere, J., & Runtz, M. (1987). Post sexual abuse trauma: Data and implications for clinical practice. Journal of Interpersonal Violence, 2, 367–379. Brown, S.A., Inaba, R.K., Gillin, J.C., Schuckit, M.A., Stewart, M.A., and Irwin, M.R. (1995). Alcoholism and affective disorder: Clinical course of depressive symptoms. American Journal of Psychiatry, 152, 45–52. Brown, P.J., & Wolfe, J. (1994). Substance abuse and post-traumatic stress disorder comorbidity. Drug and Alcohol Dependence, 35, 51–59. Burnam, M.A., Stein, J.A., Golding, J.M., Siegel, J.M., Sorenson, S.B., Forsythe, A.B., & Telles, C.A. (1988). Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843–850. Cottler, L.B., Compton, W.M., Mager, D., Spitznagel, E.L., & Janca, A. (1992). Posttraumatic stress disorder among substance abusers from the general population. American Journal of Psychiatry, 149, 664–670. Dansky, B.S., Saladin, M., Brady, K.T., Kilpatrick, D.G., & Resnick, H.S. (1995). Prevalence of victimization and PTSD among women with substance use disorders: Comparison of telephone and in-person assessment samples. International Journal of the Addictions, 30, 1079–1100. Derogatis, L.R. (1977). SCL-90-R: Administration, scoring, and procedures manual-II. Towson, MD: Clinical Psychometric Research. Derogatis, L.R. (1983). SCL-90-R: Manual II. Towson, MD: Clinical Psychometric Research. Falsetti, S.A., Resick, P.A., Resnick, H.S., & Kilpatrick, D.G. (1992). Post-traumatic stress disorder: The assessment of the frequency and severity of symptoms in clinical and nonclinical samples. Paper presented at the 26th Annual Convention of the Association for Advancement of Behavior Therapy, Boston, MA. Falsetti, S.A., Resnick, H.S., Resick, P.A., & Kilpatrick, D.G. (1993). The modified PTSD symptom scale: A brief self-report measure of posttraumatic stress disorder. Behavior Therapist, 16, 161–162.
Foa, E.B., Riggs, D.S., Dancu, C.V., & Rothbaum, B.O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473. Gawin, F.H. & Kleber, H.D. (1986). Abstinence symptomatology and psychiatric diagnosis in cocaine abusers. Archives of General Psychiatry, 43, 107–113. Grice, D.E., Brady, K.T., Dustan, L.R., Malcolm, R., & Kilpatrick, D.G. (1995). Sexual and physical assault history and posttraumatic stress disorder in substance-dependent individuals. American Journal on Addictions, 4, 297–305. Halikas, J.A., Kuhn, K.L., Crea, F.S., et al. (1981). Treatment of crack cocaine use with carbamazepine. American Journal of Drug and Alcohol Abuse, 18, 45–46. Helzer, J.E. (1984). The impact of combat on later alcohol use by Vietnam veterans. Journal of Psychoactive Drugs, 16, 183–191. Horowitz, J., Wilner, N., & Alvarez, W. (1979). Impact of event scale: Measure of subjective stress. Psychosomatic Medicine, 41, 209– 218. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. Kilpatrick, D.G., Acierno, R., Resnick, H.S., Saunders, B.E., & Best, C.L. (1997). A two-year longitudinal analysis on the relationships between violent assault and substance use in women. Journal of Consulting and Clinical Psychology, 65, 834–847. Kilpatrick, D.G., Resnick, H.S., Saunders, B.E., & Best, C.L. (1989). The National Women’s Study PTSD Module. Unpublished instrument. Charleston, South Carolina Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina. Kosten, T.R., & Krystal, J. (1988). Biological mechanisms in posttraumatic stress disorder: Relevance for substance abuse. In M. Galanter (Ed.), Recent developments in alcoholism. New York: Plenum Publishing. Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, K.B., Marmar, C.R., and Weiss, D. (1990). Trauma and the Vietnam War generation. New York: Brunner/Mazel. McClellan, A.T., Parikh, G., & Bragg, A. (1990). Addiction Severity Index manual (5th Ed.). Philadelphia: University of Pennsylvania Center for the Study of Addiction. Mullaney, J.A., & Trippett, C. (1979). Alcohol dependence and phobias: Clinical description and relevance. British Journal of Psychiatry, 135, 565–573. Resnick, H., Kilpatrick, D.G., Dansky, B.S., Saunders, B.E., & Best, C.L. (1993). Prevalence of civilian trauma and post-traumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984–991. Saladin, M.E., Brady, K.T., Dansky, B.S., & Kilpatrick, D.G. (1995). Understanding comorbidity between PTSD and substance use disorders: Two preliminary investigations. Addictive Behavior, 20, 643–655. Satel, S.L., Price, L.H., Palumbo, J.M., McDougle, C.J., Krystal, J.H., Gawin, F., Charney, D.S., Heninger, G.R., and Kleber, H.D. (1991). Clinical phenomenology and neurobiology of cocaine abstinence: A prospective inpatient study. American Journal of Psychiatry, 148, 1712–1716. Saunders, B.E., Arata, C.M., & Kilpatrick, D.G. (1990). Development of a crime-related post-traumatic stress disorder scale for women within the Symptom Checklist-90-Revised. Journal of Traumatic Stress, 3, 439–448. Schuckit, M.A., Irwin, M., Howard, D., & Smith, E. (1988). A structured diagnostic interview for identification of primary alcoholism: A preliminary evaluation. Journal of Studies on Alcohol, 49, 93–99. Schuckit, M.A., & Monteiro, M.G. (1988). Alcoholism, anxiety, and depression. British Journal of Addiction, 83, 1373–1380. Small, P., Stockwell, T., Canter, S., & Hodgon, R. (1984). Alcohol dependence and phobic anxiety states I: A prevalence study. British Journal of Psychiatry, 144, 53–57.
504 Sobell, M.D., & Sobell, L.C. (1978). Behavior treatment of alcohol problems. New York: Plenum Press. Spitzer, R.L., Williams, J.B., & Gibbon, M. (1987). Structured Clinical Interview for DSM-III-R-Nonpatient Version (SCID-NP-V). New York: New York State Psychiatric Institute, Biometrics Research Department. Stasiewicz, P.R., & Maisto, S.A. (1993). Two-factor avoidance theory: The role of negative affect in the maintenance of substance use disorders. Behavior Therapy, 24, 337–356. Thevos, A.K., Johnston, A.L., Latham, P.K., Randall, C.L., & Malcolm, R. (1991). Symptoms of anxiety in inpatient alcoholics with
B.S. Dansky et al. and without DSM-III-R anxiety diagnoses. Alcoholism, Clincial and Experimental Research, 15, 102–105. Weddington, W.W., Brown, B.S., Haertzen, C.A., Cone, E.J., Dax, E.M., Herning, R.I., and Michaelson, B.S. (1990). Changes in mood, craving, and sleep during short-term abstinence reported by male cocaine addicts. Archives of General Psychiatry, 47, 861–868. Wolfe, J., & Kimerling, R. (1997). Gender issues and assessment of posttraumatic stress disorder. In J.P. Wilson & T.M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 192–238). New York: Guilford Press.
PII S0740-5472(97)00293-6
ARTICLE
Untreated Symptoms of PTSD Among Cocaine-Dependent Individuals Changes Over Time
Bonnie S. Dansky, phd, Kathleen T. Brady, md, phd, and Michael E. Saladin, phd Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Center for Drug and Alcohol Programs, Charleston, SC
Abstract – Changes over time in posttraumatic stress disorder (PTSD) symptoms during periods when individuals with substance use disorders remain abstinent has not received much attention. PTSD symptomatology over a 36-month period was studied in cocaine-dependent individuals (N 5 34) who entered a pharmacologic trial targeting cocaine use and depression, but did not include any treatment for PTSD. All participants reported at least one PTSD Criterion A event, and 17.6% had current PTSD at baseline (Base PTSD1). Significant improvements in PTSD symptoms were observed on global measures of PTSD, but not on the Impact of Events Intrusion subscale. Significant improvement in drug use severity also was observed. Compared with participants who were negative for PTSD at baseline, Base PTSD1 participants were significantly more likely to: (a) meet criteria for current PTSD at follow-up and (b) have been re-victimized over the time period of the study. Careful evaluation of intrusive symptoms may be particularly important when diagnosing PTSD in individuals with SUDs, and repeated assessment of traumatic experiences may be necessary in longitudinal studies. © 1998 Elsevier Science Inc. Keywords – posttraumatic stress disorder; substance use disorder; assessment, revictimization.
INTRODUCTION
have demonstrated that substance use disorders (SUDs) are more prevalent in individuals with a history of criminal victimization and/or PTSD than in people who are negative for such a history. Similarly, high rates of victimization and PTSD have been observed in persons with SUDs sampled from the general population and treatment facilities (e.g., Brown & Wolfe, 1994; Cottler et al., 1992; Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995; Grice, Brady, Dustan, Malcolm, & Kilpatrick, 1995; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Although researchers have documented a high rate of PTSD in individuals with SUDs, changes over time in PTSD symptoms during abstinent periods as opposed to periods of active use in persons with comorbid SUDs have not received much, if any, attention. Several researchers have observed that symptoms of depression and anxiety may be exaggerated during early recovery from alcohol
OVER THE PAST 10 years numerous national and community-based studies have documented a high co-occurrence of posttraumatic stress disorder (PTSD), victimization, and substance use disorders (Burnam et al., 1988; Cottler, Compton, Mager, Spitznagel, & Janca, 1992; Helzer, 1984; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Kulka et al., 1990). Epidemiologic studies
This project was supported by National Institute on Drug Abuse (NIDA) Grant No. DA07761 awarded to Kathleen T. Brady, MD, PhD. Requests for reprints should be addressed to Bonnie S. Dansky, PhD, Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Center for Drug and Alcohol Programs, 171 Ashley Avenue Charleston, SC 29425-0742. E-mail: bonnie dansky @smtpw.musc.edu
Received July 18, 1997; Accepted November 3, 1997.
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and dissipate with time in abstinence alone (Bowen, Cipywnyk, D’Arcy, & Keegen, 1984; Brown et al., 1995; Gawin & Kleber, 1986; Halikas et al. 1981; Mullaney & Trippett, 1979; Satel et al., 1991; Schuckit & Monteiro, 1988; Schuckit, Irwin, Howard, & Smith, 1988; Small, Stockwell, Canter & Hodgon, 1984; Thevos, Johnston, Latham, Randall, & Malcolm, 1991; Weddington, et al., 1990). Similarly, there is empirical evidence suggesting that withdrawal from drugs of abuse, such as cocaine and alcohol, can produce high levels of anxiety, and therefore, assessments conducted during periods of active use or early withdrawal may lead to inflated estimates of anxiety disorders (Bowen et al., 1984; Halikas et al., 1981; Mullaney & Trippett, 1979; Satel et al., 1991; Schuckit & Monteiro, 1988; Schuckit et al., 1988; Small et al., 1984; Weddington et al., 1990). As a result of studies suggesting an increase in anxiety during early drug and alcohol withdrawal, it has been suggested that diagnosis of most anxiety and affective disorders not be made during early recovery. This issue has not been addressed for PTSD, however, and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) provides no guidance concerning diagnosis of this disorder during periods of active use and early recovery. It is clear that symptoms of hyperarousal may be exaggerated during withdrawal periods. Activation of the locus coerulus is a part of withdrawal syndromes and has been implicated in PTSD symptoms (Kosten & Krystal, 1988). Moreover, it is possible that symptoms of avoidance may be caused by drug-using lifestyle, wherein avoidance of persons, places, and activities can occur for reasons associated with drug procurement and use. Furthermore, a behavioral theory of addiction (Stasiewicz & Maisto, 1993) suggests that individuals experiencing psychological distress seek drugs to self-medicate and dampen their emotional symptoms, which would result in an initial exacerbation of psychological symptomatology when the drug is removed. In order to clarify the course of untreated PTSD symptoms over time in patients with cocaine dependence, in-depth trauma and PTSD evaluations were conducted in a sample of cocaine dependent individuals at the time of entry into a pharmacologic trial and a the 3-month follow-up point. MATERIALS AND METHODS Subjects Participants were 34 individuals, out of a total of 93, who participated in an outpatient pharmacologic treatment trial of carbamazepine for the treatment of cocaine dependence, underwent a thorough trauma screening at baseline, and were located for a 3-month follow-up appointment. All participants met criteria for cocaine dependence, and individuals with psychotic disorders or who were cognitively impaired were excluded from
study participation. Participants were not encouraged or dissuaded from involvement in standard substance abuse interventions that were available at the institution and/or in the community (group treatment, self-help, etc.). However, none of the participants received treatment specifically designed to alleviate symptoms of PTSD. There were 20 men and 14 women in the sample, with a mean age of 32.0 (SD 5 5.5) at baseline. The sample was almost evenly split between African American (52.9%) and Caucasian (47.1%), with no other minorities, which is typical of small cities on the Southeastern seaboard. A majority of the participants completed high school/trade school (44.0%) or attended some college (32.4%), although a significant minority had dropped out of high school (23.5%). Most of the participants were unemployed (52.9%), and 53.6% had a yearly family income below $15,000. Another 8.8% had an income between $15,000 and $25,000, and the remaining participants (17.6%) reported an income above $25,000. Chi-square statistics were calculated to compare participants who were in the follow-up sample with those in the original sample who were not located for follow-up (nonparticipants). No significant differences were observed for gender, race, educational status, employment status, socioeconomic status, or the prevalence of current PTSD (17.6% for the participants vs. 24.6% for nonparticipants, x2[1] 5 0.59, p 5 .44). Instruments Substance Use and Psychiatric Assessment. Substance use disorders were evaluated using the Addiction Severity Index (ASI; McClellan, Parikh, & Bragg, 1990), a modified version of the Time Line Follow-Back (Sobell & Sobell, 1978), and urine drug screen. The Structured Clinical Interview for DSM-III-R (SCID-R; Spitzer, Williams, & Gibbon, 1987) was used to ascertain the diagnosis of cocaine dependence and psychiatric disorders. Trauma and PTSD Assessment. A history of traumatic events was evaluated at baseline (study entry) using Part I of the National Women’s Study PTSD Module (NWS; Kilpatrick, Resnick, Saunders, & Best, 1989), which includes behaviorally specific questions about sexual assault, physical assault, witnessing homicide, natural disaster, combat, serious/life-threatening accidents, and any other life-threatening events (see Dansky et al. 1995; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993 for details). Part II of the NWS was used to evaluate symptoms of PTSD, in accordance with Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) criteria. Patients were classified as meeting current PTSD if they met diagnostic criteria within 6 months of the interview. Self-Report Assessment. The following self-report measures were used to evaluate PTSD: (a) Modified PTSD
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Symptom Scale-Self Report (MPSS-SR; Falsetti, Resick, Resnick, & Kilpatrick, 1992; Falsetti, Resnick, Resick, & Kilpatrick, 1993) is a modified version of the PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993) that includes 21 items designed to assess symptoms of PTSD, including their frequency and intensity; (b) Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) is a 15-item self-report scale designed to measure the extent to which a given stressful life event produces subjective distress; and (c) Symptom Check List 90-Revised (SCL-90-R; Derogatis, 1977, 1983) is a 90-item self-report symptom inventory designed to reflect psychological symptom patterns and has an empirically derived subscale to measure PTSD (Saunders, Arata, & Kilpatrick, 1990). Procedure Participants were interviewed and completed self-report questionnaires upon study entry and again at a follow-up that occurred 3 months after the 12-week study was finished. The interviewer received in-depth training on all diagnostic instruments and remained blind to the study conditions. Self-report assessments of trauma-related symptoms were administered to all participants who indicated that they had experienced at least one traumatic event during their life. RESULTS Based on the results of the NWS interview, the prevalence rate of current PTSD was 17.6% at baseline (Base PTSD1). Therefore, the “Base PTSD2” group comprised 82.4% of the sample. Of the total sample, 11.5% met criteria for current PTSD at follow-up. Forty percent of the participants who met criteria for current PTSD at baseline continued to meet criteria at the follow-up, compared with 4.8% who had not met criteria at baseline but did so at follow-up. At baseline, participants reported a
FIGURE 1. Frequency of traumatic events.
high number of traumatic experiences (see Figure 1). All 34 participants reported at least one event that met the specifications for PTSD Criterion A (DSM-III-R). Since virtually all participants in the study experienced a traumatic event, changes in self-report scores on PTSD measures were examined using the entire sample (see Figure 2). Paired sample t-tests were calculated between MPSS, SCL-90-R PTSD, IES Intrusion, and IES Avoidance scores at baseline and follow-up. There were significant improvement in scores over time on the MPSS, t(17) 5 4.71, p , .001, and SCL-90-R PTSD subscale, t(18) 5 3.48, p , .005. There was marginally significant improvement over time obtained on the IES Avoidance subscale, t(21) 5 2.01, p , .06, but no significant improvement was observed for scores on the IES Intrusion subscale. A Fisher’s Exact Test was calculated to compare the rate of new traumatic events among participants who were in the Base PTSD1 and Base PTSD2 groups. The proportion of new traumatic events was significantly higher among the participants in the Base PTSD1 group (83.3%) as compared with those in the Base PTSD2 group (35.7%; Fisher’s Exact Test 5 0.046). In order to ascertain whether the self-report scores at follow-up were influenced by any new traumatic experiences that occurred while the participant was in the study or during the follow-up period, changes in self-reported PTSD scores were examined in participants who had experienced a new trauma (n 5 11) and those who had not (n 5 7). There were no significant group differences regarding the extent of change over time on the MPSS, SCL-90-R PTSD subscale, IES Intrusion subscale, and IES Avoidance subscale. Therefore, the changes observed on these measures likely do not simply reflect participants’ new traumatic experiences. In order to determine whether the differences in PTSD symptoms as measured by the self-report instruments resulted from the pharmacologic intervention, comparisons were made between participants who received carbamazepine (n 5 17) and those in the placebo control group (n 5 17). No differences between participants in the drug and control groups were observed in the prevalence of current PTSD at baseline (17.6% drug vs. 17.6% control) or at follow-up (15.4% drug vs. 7.7% control). Similarly, comparisons calculated to compare drug and control group self-report scores did not reveal any significant differences on any of the PTSD measures. Therefore, the changes in untreated PTSD symptoms did not appear to have been influenced by the drug condition in which the participants were assigned. Comparisons (t-tests) were made between scores on the ASI at baseline and at follow-up to determine whether the changes in PTSD observed were accompanied by changes on a multidimensional measure of addiction severity (see Figure 3). For the entire sample there were significant improvements on the ASI Drug, t(25) 5 10.02, p , .00, and Family, t(24) 5 2.53, p ,
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FIGURE 2. Changes in self-reported posttraumatic stress disorder (PTSD) symptoms from baseline to follow-up. h, Baseline; j, follow-up. * p , .05; † p , .06.
.02, subscales at the follow-up assessment. In addition, participants in the Base PTSD1 group scored significantly higher at follow-up for the Legal subscale of the ASI than participants in the Base PTSD2 group, t(24) 5 2.74, p , .015. No other group differences on ASI subscale scores at follow-up were observed. DISCUSSION The topic of diagnosis and symptom profile of PTSD in the face of substance use disorders is understudied. In order to examine the extent of change in untreated symptoms of PTSD in cocaine-dependent individuals, trauma and PTSD interviews were conducted at baseline and at the 3-month follow-up, with a sample of participants in a pharmacologic trial of carbamazepine for cocaine dependence. Significant improvements in PTSD symptoms were observed on global measures of PTSD, and marginally
FIGURE 3. Changes from baseline to 36-week follow-up for Addiction Severity Index (ASI) subscale scores. h, Baseline; j, follow-up. * p , .05.
significant improvement was found for symptoms of avoidance on the IES. However, no significant improvement was evidenced on the IES Intrusion subscale. Significant improvement on a measure of addiction severity was observed for the Drug and Family subscales, and participants with current PTSD at baseline experienced less improvement at follow-up with regard to legal matters than participants negative for current PTSD at baseline. The finding of improvement over time on global measures of PTSD symptomatology, as participants also experienced decreases in drug use severity, is consistent with studies of other anxiety and affective disorders and drug abstinence/withdrawal (Thevos et al., 1991). Thevos and colleagues (1991) found that Hamilton Anxiety scores decreased by approximately 30% during a 3-week period in a group of alcoholics in early recovery. Furthermore, Brown and colleagues (1995) noted 3 weeks of abstinence from alcohol was necessary in order to make an accurate diagnosis of depression, since in primary alcoholics symptoms of depression often resolve following the detoxification process. Of interest in this study was the finding that the decrease in PTSD symptoms was not uniform across symptom clusters. Symptoms of intrusion, such as flashbacks, intrusive thoughts, and nightmares, were the most persistent over time. It is possible that intrusive symptoms that are more specific to PTSD and the traumatic event involved are less influenced by cocaine intoxication or withdrawal, and therefore, are less likely to change as a result of participation in a study addressing cocaine dependence alone. Other studies have demonstrated that symptoms of intrusion were the least likely of the PTSD symptom clusters to be influenced by substance use (Saladin, Brady, Dansky, & Kilpatrick, 1995). Many of the avoidance and hyperarousal symptoms of PTSD, such as avoidance of others, feeling detached from others, emotional numbing, irritability, and sleep disturbance, could be exacerbated or even created temporarily by early cocaine withdrawal. This would lead to higher levels of symptom endorsement of these two symptom clusters at the baseline evaluation as compared to the follow-up. In contrast, it is likely that there is much less symptom overlap between symptoms of cocaine withdrawal and symptoms of intrusion. Thus, the level of symptom endorsement for intrusions remains more stable from baseline to follow-up. Another possibility is that PTSD intrusive symptoms are more steadfast and less likely to change without the use of treatment interventions specifically designed to treat PTSD. Careful evaluation of intrusive symptoms may be particularly important when diagnosing PTSD in individuals with SUDs. The finding that the prevalence of new traumatic events was significantly higher in participants with PTSD at baseline than those without PTSD is noteworthy. This constitutes further evidence to support the observation that having PTSD is a risk factor for revictimization (Briere & Runtz, 1987; Wolfe & Kimerling,
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1997). The finding also indicates how important it is to repeatedly evaluate trauma history with participants in a longitudinal study, since a substantial proportion of them will experience new traumas while enrolled. The current study was limited in scope, given the small sample and the fact that all participants were cocaine dependent with no dependence on any other drugs. In addition, only a small proportion of the initial sample was located for follow-up, although the nonparticipants did not appear to differ from participants on important demographic and diagnostic variables. Future studies concerning changes in untreated PTSD in patients with substance use disorders should: include individuals with dependence on other drugs, which may differentially influence PTSD symptomatology; follow patients for a longer period of time; and carefully measure the exact nature of the standard substance treatment and of substance use during the evaluation period.
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