Benzodiazepine use in posttraumatic stress disorder among veterans with substance abuse

Veterans with posttraumatic stress disorder (PTSD) and substance abuse may abuse benzodiazepines and develop violent dyscontrol when using them. A total of 370 veterans were compared by substance abuse diagnosis (50%), benzodiazepine use (36%), and their interaction on 1-year outcomes after inpatient discharge. Substance abusers were less likely to be prescribed benzodiazepines (26% vs. 45%). No outcome showed a differential worsening by substance abuse or benzodiazepines, although some baseline differences were noted. Outpatient health care utilization was lower in benzodiazepine users (47 vs. 33 visits). Among PTSD patients with comorbid substance abuse, benzodiazepine treatment was not associated with adverse effects on outcome, but it may reduce health care utilization.     

The costs and outcomes of treatment for opioid dependence associated with posttraumatic stress disorder

OBJECTIVE: This study examined the costs and outcomes of treatment for opiate dependence associated with posttraumatic stress disorder (PTSD). METHODS: Data were collected on the use of opiate treatment over a 12-month period for a cohort of 495 individuals, of whom 42 percent had PTSD. Total treatment costs were calculated as the sum of the time spent in each treatment modality multiplied by the appropriate unit cost. Outcome measures included occupational functioning, use of heroin and other drugs, and physical and mental health. RESULTS: No significant difference was noted in the cost of treatment over the 12-month period for persons with and without PTSD (5,394+/-5,136 and 4,821+/-5,144 [Australian dollars], respectively). However, persons with PTSD had poorer treatment outcomes in terms of occupational functioning, overdose, and physical and mental health. CONCLUSIONS: Although the same resources were invested in opiate treatment for persons with and without PTSD, PTSD continued to be associated with poorer functioning in a number of domains at 12-month follow-up. A well-designed intervention targeting both heroin dependence and PTSD may help to improve the outcomes of persons with PTSD.     

Trauma and comorbid posttraumatic stress disorder in individuals with schizophrenia and substance abuse

Objectives

The aim of this study was to investigate the occurrence of trauma and comorbid posttraumatic stress disorder (PTSD) in dual diagnosis patients and whether the trauma was related to the patient's behavior or illness.

Method

One hundred ten patients with schizophrenia and comorbid substance or alcohol abuse were assessed for PTSD using self-report and structured interview. Traumatic events were classified as independent or dependent upon the patient's behavior, illness, or symptoms.

Results

One hundred patients (91%) reported at least 1 trauma (mean, 4.3). Sixty-three patients (57%) reported a traumatic event that met modified-criterion A for PTSD. Thirty-one patients (28%) met criteria for full PTSD, and 18 (16%) had a trauma directly related to their illness. Patients with PTSD had significantly higher scores on positive psychotic symptoms and depression.

Conclusions

Exposures to traumatic events and comorbid PTSD are high but are inflated by reactions to illness-related events such as hospitalization and psychotic symptoms.     

Discriminative delay Pavlovian eyeblink conditioning in veterans with and without posttraumatic stress disorder

BACKGROUND: Impaired eyeblink (EB) classical conditioning using a delay paradigm has previously been shown in combat veterans, as well as in a group of depressed adults, compared to normal individuals. Significant deficits in immediate memory (IM) in combat PTSD+ veterans, compared to normal controls, have also been previously shown, but these differences became non-significant after controlling for level of self-reported depression. Furthermore, EB conditioning has been shown to be significantly correlated with heart rate variability (HRV) in normal adults. The present study examined how depression (self-reported), IM, and resting HRV are related to discriminative delay classical EB conditioning in veterans with and without PTSD. METHOD: Three groups of subjects (combat PTSD+, combat PTSD-, and non-combat PTSD-) were assessed for self-report of depression and anxiety, as well as IM and HRV. Subjects received a single session of discriminative EB classical conditioning in which the conditioned stimulus (CS) was a light signal (either red or green) compounded with a tone. On CS+ trials, the light-tone compound stimulus co-terminated with a corneal airpuff (unconditioned stimulus, US), thus producing a delay paradigm. On CS- trials the appropriate light-tone stimulus was presented but not followed by the airpuff US. EB amplitude and frequency were recorded. RESULTS: PTSD+ subjects had greater self-reported depression and anxiety scores than the two control groups, as well as lower scores on a measure of IM. However, the IM difference was not significant after the effects of self-reported depression and anxiety were controlled. EB CR amplitude was significantly greater to CS+ than CS- for all three groups. EB amplitude to both the US (airpuff) and the CS+ declined over trials, but was significantly lower in the combat PTSD+ group compared to the combined PTSD- groups. Subjects who reached an EB CR acquisition criterion had significantly greater scores on IM than those who did not reach criterion. Factor analysis of the entire data set revealed four factors corresponding to (1) self-reported depression and anxiety, (2) IM, (3) HRV, and (4) EB amplitude. EB frequency was significantly predicted by IM and HRV. CONCLUSIONS: These data extend our previous results by showing deficits in EB conditioning among combat PTSD+ veterans that were associated with lower IM and resting HRV, but were not associated with self-report of depression.     

Hippocampal volume in borderline personality disorder with and without comorbid posttraumatic stress disorder: A meta-analysis

Background

Several studies have found a reduction in hippocampal volume in borderline personality disorder (BPD) patients.

Methods

In order to investigate the degree to which comorbid posttraumatic stress disorder (PTSD) could account for reduction in hippocampal volume in these patients, we conducted a systematic review and meta-analysis of studies that compared hippocampal volume in BPD patients with and without PTSD relative to healthy controls.

Results

Seven articles, involving 124 patients and 147 controls, were included. We found a statistically significant reduction for the left and right hippocampus. Data from the four studies that discriminated BPD patients with and without PTSD indicate that hippocampal volumes were reduced bilaterally in BPD patients with PTSD, relative to healthy controls, but that results were mixed for BPD patients without PTSD, relative to healthy controls.

Conclusions

Results from this meta-analysis suggest that hippocampal volumes are reduced in patients with BPD, relative to healthy controls, but particularly in cases in which patients are diagnosed with comorbid PTSD.     

Electroconvulsive therapy for comorbid major depressive disorder and posttraumatic stress disorder

OBJECTIVE: Posttraumatic stress disorder (PTSD) and major depressive disorder frequently co-occur. Electroconvulsive therapy (ECT) is the most effective treatment for refractory major depressive disorder. We examined the effect of ECT in patients with co-occurring major depression and PTSD. METHOD: Using a retrospective chart review, we examined the outcome of the cases of 26 patients with major depression and co-occurring PTSD who received a course of ECT. The patients received either suprathreshold right unilateral, bilateral, or a combination of both. Using paired t test analysis, we compared the pretreatment and the posttreatment symptoms using the Montgomery-Asberg Depression Rating Scale and the PTSD Checklist. RESULTS: The patients receiving ECT had a significant reduction in the symptoms of major depression and some amelioration in PTSD symptoms. CONCLUSIONS: Electroconvulsive therapy may be an effective treatment for patients with refractory depression and co-occurring PTSD.     

Body mass index in male Caucasian veterans with or without posttraumatic stress disorder

Obesity (defined as body mass index (BMI) higher than 30), is a serious and global public health problem, associated with increased morbidity and mortality and it represents a risk factor for developing various somatic and psychiatric disorders. Combat-related posttraumatic stress disorder (PTSD) is frequently associated with increased BMI which leads to overweight and obesity. We therefore evaluated BMI in the ethnically uniform Croatian male participants of the Caucasian origin, combat exposed veterans with or without PTSD, controlled for the effect of trauma, age, smoking, alcohol consumption, physical activity and comorbid psychiatric disorders, and in age matched healthy control subjects. BMI did not differ significantly between veterans with or without PTSD and healthy control subjects, or when participants were subdivided according to the age groups, BMI categories, or the presence of psychiatric disorders. Limitation of the study might be a small number of veterans with or without PTSD. Similar BMI was found in Croatian male veterans with or without PTSD, and age matched healthy control subjects. The data provided evidence of overweight and obesity in large number of veterans but also in healthy control subjects, and indicated that public health organizations should develop more effective strategies to prevent overweight and obesity.     

Methodology of a randomized double-blind clinical trial for comorbid posttraumatic stress disorder and alcohol dependence

INTRODUCTION: Alcohol dependence (AD) and posttraumatic stress disorder (PTSD) are each associated with profound disruptions in psychological, social, and physical functioning, and these disruptions are compounded in individuals with both disorders. Comorbidity between the two disorders is high, with the risk for AD increasing substantially among individuals with PTSD and, conversely, PTSD is highly prevalent among people experiencing AD. AIMS: Given the increased impairment associated with this comorbidity, it is imperative to develop effective treatments for individuals who experience both disorders. METHODS: This paper describes the methodology of a study that examines the efficacy of prolonged exposure therapy alone, naltrexone alone, and their combination compared to pill placebo in reducing the severity of PTSD and alcohol use in individuals with comorbid AD and PTSD. DISCUSSION: Issues related to design, assessment, treatment choice, and challenges posed by the study population are discussed.     

Alexithymia among Vietnam veterans with posttraumatic stress disorder

The authors studied 227 inpatients from a large Veterans Administration Medical Center to evaluate whether alexithymia is associated with posttraumatic stress disorder (PTSD) and to assess the validity of the Minnesota Multiphasic Personality Inventory (MMPI) alexithymia scale. Three groups--a carefully diagnosed PTSD group (N = 76), an alcohol abuse group (N = 76), and a general psychiatric group (N = 75)--were given a battery of psychological tests, including the MMPI, the Millon Clinical Multiaxial Inventory, and the Beck Depression Inventory, along with several cognitive measures. PTSD veterans were also evaluated on psychophysiologic indices (including a stressor) and on their subjective ratings to these indices. Results showed that alexithymia was more characteristic of PTSD patients than of the other groups. Also, alexithymia was inversely related to heart rate. Alexithymia was not significantly correlated with the subjective experience of stressors. The authors discuss the importance of the construct of alexithymia among PTSD patients and recommend the use of the alexithymia scale for these patients. The independence of this measure from the psychophysiologic condition of hyperarousal and the subjective experience of this state were also addressed.     

Drug treatment outcomes for adolescents with comorbid mental and substance use disorders.

This study compared the pretreatment characteristics and posttreatment outcomes of substance-abusing adolescents with and without comorbid mental disorders in the Drug Abuse Treatment Outcome Studies for Adolescents. Subjects (N = 992) were sampled from 23 adolescent drug treatment programs across three modalities (residential, short-term inpatient, outpatient drug-free). Nearly two thirds (64%) of the sample had at least one comorbid mental disorder, most often conduct disorder. Comorbid youth were more likely to be drug or alcohol dependent and had more problems with family, school, and criminal involvement. Although comorbid youth reduced their drug use and other problem behaviors after treatment, they were more likely to use marijuana and hallucinogens, and to engage in illegal acts in the 12 months after treatment, as compared with the noncomorbid adolescents. Integrated treatment protocols need to be implemented within drug treatment programs in order to improve the outcomes of adolescents with comorbid substance use and mental disorders.     

Comparison of comorbid physical illnesses among veterans with PTSD and veterans with alcohol dependence

Posttraumatic stress disorder (PTSD) is associated with high rates of medical service use and with self-reported poor health. Male veterans admitted to a rehabilitation unit for PTSD (N=55) or alcohol dependence (N=38) were evaluated for comorbid psychiatric and medical conditions and health risk factors. Patients with PTSD were more likely to have osteoarthritis, diabetes, heart disease, comorbid depression, obesity, and elevated lipid levels. These findings suggest that there may be a relationship between specific medical conditions, possibly mediated by behavioral risk factors, among the aging population of veterans with PTSD.     

Group therapy program for African-American veterans with posttraumatic stress disorder

A Vet Center's group therapy treatment program for African-American veterans with posttraumatic stress disorder (PTSD) has met regularly and expanded since it was established in 1984. Program attributes described by participants as particularly helpful include facilitating open communication of thoughts and feelings among African-American men; providing support for coping with the intrapsychic, social, and economic effects of racism; increasing knowledge about the causes, consequences, and treatment of PTSD; and decreasing emotional and social isolation. The program appears to be a useful treatment for African-American veterans with PTSD.     

Attention-deficit/hyperactivity disorder comorbidity in a sample of veterans with posttraumatic stress disorder

This study examined attention-deficit/hyperactivity disorder (ADHD) comorbidity in military veterans with a high prevalence of posttraumatic stress disorder (PTSD) and evaluated the relationships between the 2 disorders and exposure to traumatic events. The sample included 222 male and female military veterans who were administered structured clinical interviews based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Results show that 54.5% met the criteria for current PTSD, 11.5% of whom also met the criteria for current adult ADHD. Level of trauma exposure and ADHD severity were significant predictors of current PTSD severity. Evaluation of the underlying structure of symptoms of PTSD and ADHD using confirmatory factor analysis yielded a best-fitting measurement model that comprised 4 PTSD factors and 3 ADHD factors. Standardized estimates of the correlations among PTSD and ADHD factors suggested that the largest proportion of shared variance underlying PTSD-ADHD comorbidity is related to problems with modulating arousal levels that are common to both disorders (ie, hyperarousal and hypoarousal).     

Response inhibition and cognitive flexibility in schizophrenia with and without comorbid substance use disorder

Addiction is a frequent comorbid disorder in schizophrenia related to dopaminergic dysfunction in fronto-subcortical circuits. These brain networks are relevant for both (executive) cognition and the neuropathology of schizophrenia. The aim of the present study was to elucidate whether response inhibition and cognitive flexibility - executive abilities relevant for achieving and maintaining abstinence - are differentially impaired in schizophrenia patients with or without comorbid substance use disorder. Patients suffering from major depression or alcoholism as well as healthy controls served as comparison groups. The ability to inhibit predominant response tendencies during response conflict and to efficiently shift the focus of attention between different task requirements was assessed by verbal and non-verbal cognitive tasks. Contrary to expectation, non-addicted schizophrenia patients showed the most pronounced executive function impairments relative to the control groups, affecting both response suppression and cognitive flexibility. Dual diagnosis patients did not differ significantly from non-addicted schizophrenia patients or from the alcoholic group, but were impaired at cognitive flexibility relative to the depression subgroup and healthy controls. Whether the relative preservation of response inhibition and cognitive flexibility in the dual disorder patients is due to high premorbid functioning, beneficial self-medication effects or compensatory brain activation remains to be elucidated. The relatively intact executive abilities in young, addicted schizophrenia patients might represent a beneficial resource for treatment strategies.     

Brain integrity and cerebral atrophy in Vietnam combat veterans with and without posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is associated with decreased hippocampal volume, but the relationship between trauma and brain morphology in the absence of PTSD is less clear. In this study, measures of brain integrity were determined by estimating gray and white matter regional brain volumes using structural magnetic resonance imaging in six patients with PTSD and in five controls with comparable trauma exposure but without clinical evidence of PTSD. The only statistically significant volume difference between groups was observed multivariately in the white matter of the right temporal lobe (superior temporal gyrus, fusiform gyrus, parahippocampal gyrus, white-matter stem, middle temporal gyrus, and inferior temporal gyrus), although small sample sizes limit the power to detect between-group differences. Both groups showed heterogeneity in cerebral atrophy.     

Post-september 11 admission symptoms and treatment response among veterans with posttraumatic stress disorder

OBJECTIVE: Evidence has been found of significant psychological distress after the terrorist attacks of September 11, 2001, even in communities that were not directly affected. Persons with preexisting posttraumatic stress disorder (PTSD) may be especially vulnerable to such distress. The authors examined clinical data on veterans who had a diagnosis of PTSD to determine whether the attacks exacerbated their symptoms. METHOD:S: Outcome-monitoring data were analyzed from a national sample of more than 9,000 veterans who were treated in specialized intensive PTSD programs of the Department of Veterans Affairs (VA) from March 11, 1999, to March 11, 2002. Analysis of variance was used to compare symptom levels at admission and clinical improvement during the six months before and six months after September 11 and in comparison with the same periods in 1999 and 2000. RESULTS: Veterans who were admitted after September 11, 2001, had less severe symptoms than those admitted before September 11, a pattern that was significantly different from previous years. Veterans who were followed up after September 11 showed significantly more improvement in PTSD symptoms than those who were followed up before then, which also represented a significant difference from previous years. CONCLUSION:S: VA patients with preexisting PTSD were, unexpectedly, less symptomatic at admission after September 11 than veterans admitted before September 11, and patients who had follow-up assessments after September 11 showed more improvement. It is possible that these veterans benefited from the shared feelings of national unity, pride, and patriotism in the months after September 11 as well as from the normalization of PTSD-like reactions by the news media and a sense of mastery at having past experience in coping with trauma.