Co-occurring Disorders
People who have both mental health and substance abuse problems are highly likely to have trauma histories; in fact, trauma is often their central problem.
Facts and Discussion Points:
1--Fifty-five percent of consumers and former consumers at a Maine state mental hospital with a dual diagnosis of mental illness and substance abuse report histories of physical and/or sexual abuse.1
2--In adults, the rates for co-morbid Posttraumatic Stress Disorder (PTSD) and substance use disorders are two to three times higher for females than males, with 30% to 57% percent of all female substance abusers meeting the criteria for PTSD. Women’s increased risk for co-morbid PTSD and substance dependence is related to their higher incidence of childhood physical and sexual abuse.2
3--Many mental health and substance abuse providers may be under the impression that abuse experiences are an additional problem for their clients, rather than the central problem. PTSD is often the only diagnosis utilized to address abuse; in fact, every major diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) can sometimes be related to trauma.3
4--Statistics on abuse history increase dramatically if respondents are questioned regarding emotional/mental abuses and neglect.3
5--A high prevalence of trauma exposure and PTSD exists among the dually diagnosed.4,5,6
* It is estimated that fewer than 20% of substance abuse programs offer specialized trauma-related services for the dually diagnosed.7,12.
* Among women in substance abuse treatment, rates of PTSD are double those in the general population, ranging from 30% to 59%.2
* Untreated PTSD among people with co-occurring disorders often increases the need for more frequent hospitalizations, entitlement benefits, and supportive services (Rosenberg, Mueser, Friedman, Gorman, Drake, Vidaver, Torrey, & Jankowski, 2001).6
* Up to two-thirds of men and women entering substance abuse treatment suffer PTSD or Posttraumatic Stress Symptoms (PTSS).8
* Individuals diagnosed with substance abuse disorders and PTSD, compared with those without a diagnosis of PTSD, are more likely to use inpatient and outpatient services and often seek medical rather than mental health or substance abuse treatment.9,10
* An independent assessment of recipients of public mental health inpatient and outpatient services revealed 43% had a diagnosis of PTSD not previously assessed by any of the facilities. Mental health staff had only noted a diagnosis of PTSD in the charts of 2% of the consumers (Mueser et al., 1998).4
* Both mental health and substance abuse providers may be investing significant effort providing services that are only partially related to their clients underlying causes of need (Switzer et al., 1999).11
* When compared to those without PTSD, dually diagnosed individuals with PTSD—particularly those with psychotic disorders—report significantly greater needs for comprehensive services, including drug abuse treatment services, relapse prevention, and services related to level of functioning and health issues. Trauma/domestic violence counseling was rated as very important by this group.12
* Sexual abuse and physical abuse have been identified as significant childhood risk factors for the development of addiction in adulthood.13
* Survivors of early sexual abuse may use drugs and alcohol to cope with abuse-related emotional and physical pain, abuse memories, and symptoms stemming from the abuse. PTSD symptoms are widely reported to become worse with initial abstinence. There is high probability of drug or alcohol relapse when trauma is not addressed and no alternative means of coping with the pain are provided.
14,15
* In a sample of 100 male and female subjects receiving treatment for substance abuse, more than a third were diagnosed with some form of a dissociative disorder stemming from childhood sexual or physical abuse.16
* Trauma alone is an important issue in increasing the risk of alcohol abuse. When combined with psychiatric disorder, risk significantly increases.17
* Substance abuse, posttraumatic depression, or social phobia may not be effectively managed until the trauma-based memories have been addressed.18
* Without trauma-informed interventions, there can exist a self-perpetuating cycle involving PTSD and substance abuse, where trauma (childhood or adult physical and/or sexual abuse, crime victimization, disaster, combat exposure) leads to the development of PTSD symptoms, triggering the use of alcohol and drugs, resulting in higher likelihood of subsequent traumatic events and retraumatization, leading to development of more chronic PTSD symptoms, triggering heightened substance use, and so on.19
* Substance abuse consumers with PTSD are more impaired than those without PTSD, with more co-morbid Axis I and Axis II disorders, medical problems, psychological symptoms, inpatient admissions, interpersonal problems, and lower level of functioning, lower compliance with aftercare, and reduced motivation for treatment. Women with PTSD and substance abuse have numerous co-occurring life problems, such as homelessness, loss of custody of their children, maltreatment of their children, and battered woman syndrome.19,20-28
* In adults, the rates for co-morbid PTSD and substance use disorders are two to three times higher for females than males, with 30 to 59% of all female substance abusers meeting the criteria for PTSD, most commonly deriving from a history of repetitive childhood physical and/or sexual assault.
2
* Sexual victimization in childhood and in adulthood is an important factor in dual diagnosis in women. Women with PTSD and alcohol abuse have a particularly severe level of symptoms (severe PTSD, dissociation, borderline personality traits) relative to women with only PTSD and controls.29
* Neither trauma, nor alcohol and drug problems—key risk factors that complicate psychiatric disability and recovery—are commonly identified or addressed in treatment in the mental health sector. Many clinicians lack proper training on how and when to ask about sexual abuse and substance use, how to listen to the answers, or how to incorporate this information into effective treatment.30
* Men with dual diagnoses (severe mental disorder and significant substance abuse problems) frequently have histories of trauma exposure. This group of men has usually been excluded from trauma studies.31
* An ethnographic study of the longitudinal course of substance abuse among people diagnosed with severe mental illness indicated a very close association between reported or experienced abuse in childhood at the hands of care-givers, and continuing substance use.32
* Several studies suggest that trauma sequelae must be addressed concurrently to permit successful treatment of dual diagnosis.32,33
Recommendations:
1---Develop and implement educational programs for educators and health care professionals to identify high-risk (abused) youth and offer counseling regarding their vulnerability to substance abuse.34
2---Develop and implement clinical training for substance abuse and mental health professionals that will aid in understanding co-morbidity of addiction and PTSD, identifying dual disorders, and treating trauma-related syndromes.34
3---Develop and implement academic curricula that train medical personnel, social workers, and mental health professionals to include an understanding of substance abuse and PTSD.34
4---Develop and implement specialized programs within inpatient and outpatient substance abuse facilities that offer direct treatment to trauma survivors.34
5---Train mental health and substance abuse treatment providers to assess clients/consumers for abuse/trauma histories and provide or refer to experienced trauma services.
6---Routinely assess all consumers in treatment for mental health and/or substance abuse for physical and/or sexual abuse, and refer to appropriate services if needed.
7---Cross train mental health and substance abuse services staff to ensure consistent treatment and to eliminate duplication of effort.
Co-occurring Disorders References
1. Maine Department of Behavioral and Developmental Services. (1998). Augusta Mental Health Institute consent decree class member assessment. Maine: Department of Behavioral and Developmental Services.
2. Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and Posttraumatic Stress Disorder in women. A research review. American Journal on Addictions, 6:273-283.
3. R. Mazelis (personal communication, April 2002).
4. Mueser, K. T., Goodman, L. B., Trumbetta, S. L., Rosenberg, S. D., Osher, C., Vidaver, R., Auciello, P., & Foy, D.W. (1998). Trauma and Posttraumatic Stress Disorder in severe mental illness. Journal of Consulting &Clinical Psychology, 66(3), 493-499.
5. Mueser, K. T., Rosenberg, S. D., Goodman, L. A., & Trumbetta, S. L. (2002). Trauma, PTSD, and the course of severe mental illness: An interactive model. Schizophrenia Research, 53(1-2), 123-143.
6. Rosenberg, S. D., Mueser, K. T., Friedman, M. J., Gorman, P. G., Drake, R. E., Vidaver, R. M., Torrey, W. C., & Jankowski, M. K. (2001). Developing effective treatments for posttraumatic disorders among people with severe mental illness. Psychiatric Services, 52(11), 1453-1461.
7. Bollerud, K. (1990). A model for the treatment of trauma-related syndromes among chemically dependent inpatient women. Journal of Substance Abuse Treatment, 7(2), 83-87.
8. Center for Substance Abuse Treatment. (2000). Substance abuse treatment for persons with child abuse and neglect issues Treatment Improvement Protocol (TIP) series (DHHS Publication No. SMA 00-3357, Number 36). Washington, DC: U.S. Government Printing office.
9. Kessler, R. C., Zhao, S., Katz, J., Kouzis, A. C., Frank, R. G., Edlund, M., & Leaf, P. (1999). Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry, 156(1), 115-123.
10. Ouimette, P., Brown, P., & Najavits, L. (1998). Course and treatment of patients with both substance use and Posttraumatic Stress Disorders. Addictive Behaviors, 23(6), 785-795.
11. Switzer, G. E., Dew, M. A., Thompson, K., Goycoolea, J. M., Derricott, T., & Mullins, S. D. (1999). Posttraumatic Stress Disorder and service utilization among urban mental health center clients. Journal of Traumatic Stress, 12(1), 25-39.
12. Cooper, L., Grella, C. E., Greenwell, L. (2002). Perceived need for treatment services among the dually diagnosed in drug treatment with and without Posttraumatic Stress Disorder. (under submission).
13. Blankertz, L. E., Cnaan, R. A., & Freedman, E. (1993). Childhood risk factors in dually diagnosed homeless adults. Social Work, 38(5), 587-595.
14. Zierler, S., Feingold, L., Laufer, D., Velentgas, P., Kantrowitz-Gordon, I., & Mayer, K. (1991). Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. American Journal of Public Health, 81(5), 572-575.
15. Anderson, C. M., & Chiocchio, K. B. (1997). Homeless, addictions and mental illness. In M. Harris (Ed.), Sexual Abuse in the Lives of Women (pp. 21-37). Harwood Academic.
16. Ross, C. A., Kronson, J., Koensgen, S., Barkman, K., Clark, P., & Rockman, G. (1992). Dissociation comorbidity in 100 chemically dependent patients. In Hospital and Community Psychiatry, 43(8), 840-842.
17. McFarlane, A. C. (1998). Epidemiological evidence about the relationship between PTSD and alcohol abuse: The nature of the association. Addictive Behaviours, 23(6), 813-825.
18. McFarlane, A. C. (2001). Dual Diagnosis and Treatment of PTSD. In J. P. Wilson, M. J. Friedman (Eds.), Treating Psychological Trauma and PTSD (pp.237-254). New York, NY: The Guilford Press.
19. Najavits, L. M., Gastfriend, D. R., Barber, J. P, et al. (1998). Cocaine dependence with and without PTSD in the NIDA Cocaine Collaborative Study, Am J Psychiatry.
20. Brown, P. J., Recupero, P. R., & Stout, R. (1995). PTSD substance abuse comorbidity and treatment utilization. Addict Behav, 20:251-254.
21. Grice D. E., Brady K. T., Dustan L. R., et al. (1995). Sexual and physical assault history and Posttraumatic Stress Disorder in substance-dependent individuals. Am J Addict, 4:297-305.
22. Kodoed, L., Friedman, M. J., & Peck, R. (1993). Alcoholism and drug abuse in inpatients with PTSD, Psychiatr Q, 64:151-171.
23. Brady K. T., Killeen, T., Salsdin, M. E., et al. (1994). Comorbid substance abuse and Posttraumatic Stress Disorder: Characteristics of women in treatment. Am J Addict, 3:160-164.
24. Smith, E. M., North, C. D., Spitznagel, E. L. (1993). Alcohol, drugs, and psychiatric comorbidity among homeless women: An epidemiologic study. J Clin Psychiatry, 54:82-87.
25. Paone, D., Chavkin, W., Willets, I., et al. (1992). The impact of sexual abuse: Implications for drug treatment. Journal of Women’s Health, 1:149-153.
26. Fullilove, M. T., Lown, A., Fullilove, R. E. (1992). Crack ‘hos’ and skeezers: Traumatic experiences of women crack users. Journal of Sex Research, 29:275-287.
27. Famularo, R., Kinscherff, R., Fenton, T. (1992). Psychiatric diagnoses of abusive mothers: A preliminary report. J Nerv Ment Dis, 180:658-661.
28. Levit, H. (1991). Battered women: Syndrome vs. self-defense. American Journal of Forensic Psychiatry, 9:29-35.
29. Ouimette, P. C., Wolfe, J., Chrestman, K. R. (1996). Characteristics of Posttraumatic Stress Disorder-alcohol abuse comorbidity in women. Journal of Substance Abuse, 8(3), 335-346.
30. Alexander M. J., & Muenzenmaier, K. (1998). Trauma, addiction, and recovery: Addressing public health epidemics among women with severe mental illness. In B. L. Levin, A. K. Blanch, A. Jennings (Eds.), Women’s Mental Health Services: A Public Health Perspective (pp. 215-239). Sage.
31. Freeman, D. W., & Fallot, R. D. (1997). Trauma and trauma recovery for dually diagnosed male survivors. In M. Harris (Ed.), Sexual Abuse in the Lives of Women, Chap 17. Harwood Academic.
32. Alverson H., Alverson, M., Drake, R. E. (2000). Addictions services: An ethnographic study of the longitudinal course of substance abuse among people with severe mental illness. Community Mental Health Journal, Vol. 36, No. 6. pp. 557-569.
33. Harris, M. (1998). Trauma recovery and empowerment. New York: The Free Press.
34. Steele, C. T. (2002). Providing clinical treatment to substance abusing trauma survivors. Alcoholism Treatment Quarterly, Vol.18(3).