Full length articleMarijuana dependence moderates the effect of posttraumatic stress disorder on trauma cue reactivity in substance dependent patients
Introduction
Posttraumatic stress disorder (PTSD) is characterized by the presence of re-experiencing, avoidance, and hyperarousal symptoms, as well as negative alterations in cognition and mood, following exposure to a traumatic event (American Psychiatric Association [APA], 2013). The symptoms of PTSD have the potential to result in broad functional impairment (Rodriguez et al., 2012) and contribute to the development of other psychiatric disorders (Kessler et al., 1995), especially substance use disorders (SUD; Chilcoat and Menard, 2003). Within the extant literature, the majority of studies examining the co-occurrence of PTSD and SUD have focused on alcohol or cocaine use disorders (e.g., Coffey et al., 2007, Jakupcak et al., 2010, Waldrop et al., 2007); however, there is an emerging body of literature exploring the connection between PTSD and marijuana use.
Research has shown that individuals with PTSD are at heightened risk for marijuana use. For example, in the National Comorbidity Survey, current PTSD was found to be uniquely associated with increased rates of past year marijuana use and daily marijuana use (Cougle et al., 2011). Likewise, PTSD symptom severity demonstrates a significant positive association with frequency of marijuana use (Bonn-Miller et al., 2011a, Bremner et al., 1996). Notably, the relation between PTSD and marijuana use is also clinically-relevant. Within a sample of military veterans with PTSD, Bonn-Miller et al. (2013) found that a pretreatment diagnosis of a marijuana use disorder was associated with weaker response to residential PTSD treatment even when other relevant factors (e.g., trauma severity) were considered. Similarly, PTSD symptom severity is positively associated with using marijuana to cope, marijuana use problems, and severity of marijuana withdrawal symptoms (Boden et al., 2013, Bonn-Miller et al., 2011b, Bonn-Miller et al., 2007, Earleywine and Bolles, 2014). Although these studies highlight the importance of examining the co-occurrence of PTSD and marijuana use as it relates to a variety of clinically-relevant outcomes, no studies to date have explored the way in which marijuana use may affect in-the-moment emotional responding among individuals with PTSD.
There is reason to believe that the presence of marijuana use could influence emotional responding to trauma cues among individuals with PTSD; however, the precise way in which emotional responding would be affected is unclear. For example, it is possible that individuals with PTSD may exhibit more intense emotional responses to a trauma cue in the context of marijuana use—consistent with findings that marijuana users report greater emotion dysregulation than non-users (Bonn-Miller et al., 2008). Thus, it is possible that marijuana use may further exacerbate the heightened emotion dysregulation found in PTSD (Tull et al., 2007), contributing to greater trauma cue emotional reactivity within this population. Moreover, findings that individuals with marijuana dependence exhibit greater subjective reactivity to a biological challenge (CO2 inhalation) than those with marijuana abuse (Bonn-Miller and Zvolensky, 2009) suggest that there may be a dose-response relationship with regard to the level of marijuana use and emotional reactivity.
Alternatively, an emerging body of research on the effects of marijuana use on emotional responding suggests that marijuana use may dampen emotional reactivity in response to a trauma cue among individuals with PTSD. The amygdala (an area of the brain implicated in the development and maintenance of pathological anxiety and PTSD; Liberzon and Sripada, 2007) includes a high density of CB1 cannabinoid receptors (Perra et al., 2008), activation of which diminishes anxiety responses and amygdala activation in response to aversive stimuli (Patel et al., 2005). Consequently, ingestion of Δ9-tetrahydrocannabinol (THC), the primary psychoactive ingredient in marijuana and a selective CB1 agonist, may correspond with attenuated threat-related emotional reactivity among individuals with PTSD. In support of this notion, studies have demonstrated that marijuana use is associated with reduced amygdala reactivity among individuals with comorbid marijuana dependence and major depression (Cornelius et al., 2010). Likewise, administration of THC in healthy recreational marijuana users (i.e., marijuana users who do not meet criteria for a marijuana use disorder) significantly reduced amygdala reactivity in response to threat signals (Phan et al., 2008). Moreover, Van Leeuwen et al. (2011) found that repeated marijuana users exhibit lower stress reactivity levels (as indexed by cortisol levels) than individuals who have never used tobacco or marijuana in their lifetime. Finally, individuals with marijuana dependence have been found to exhibit a reduced subjective and biological sensitivity to negative emotion cues (i.e., unpleasant pictures), relative to abstinent marijuana users and healthy controls (Somaini et al., 2012).
The purpose of the current investigation was to explore the role of marijuana dependence in the relation between PTSD and subjective and biological emotional reactivity in response to personalized trauma cues. This investigation was carried out in a sample of substance dependent patients in residential SUD treatment—a clinical population at high-risk for both PTSD and marijuana dependence (Chen et al., 2011). Given the absence of research in this area, as well as conflicting evidence with regard to the particular impact of marijuana dependence on emotional responding in PTSD, no specific hypotheses were made.
Section snippets
Participants
Participants for the current study included 202 patients (100 women) from a SUD inpatient treatment facility who reported exposure to at least one potentially traumatic event. Participants ranged from 18 to 60 years of age (Mean = 34.32, SD = 10.10) and were ethnically diverse (60.4% White; 36.6% African American; 1.5% Latina/o). With regard to educational attainment, 34.1% of participants reported receiving their high school diploma or GED and an additional 38.1% reported completing some form of
Preliminary analyses
Of the study sample, 26.7% (n = 54) met criteria for current PTSD and 29.2% (n = 59) met criteria for current marijuana dependence. Data on the distribution of participants across the different groups are presented in Table 2. Pre- and post-script descriptive data for subjective emotional reactivity and cortisol reactivity as a function of PTSD and marijuana dependence status are presented in Table 3. There was no significant difference in rates of marijuana dependence between participants with
Discussion
The goal of this study was to examine the moderating role of marijuana dependence on the relation between PTSD and subjective and biologically-indexed emotional reactivity to a personalized trauma cue. Results revealed that current PTSD was associated with greater subjective emotional reactivity to the trauma script only among participants without marijuana dependence; among those with marijuana dependence, subjective emotional reactivity did not differ as a function of PTSD status. Moreover,
Conflict of interest
No conflicts declared.
Funding
The funding source (the National Institute on Drug Abuse of the National Institutes of Health) had no involvement in this study.
Contributors
Drs. Tull and Gratz oversaw the study from which these data came. All authors were equally involved in study conceptualization, data analysis, and the writing of this manuscript.
Acknowledgements
This study was funded in part by R21 DA030587, awarded to Dr. Tull from the National Institute on Drug Abuse of the National Institutes of Health. The authors would like to thank the Mississippi State Hospital Chemical Dependence Units and the Bureau of Alcohol and Drug Services of the Mississippi State Department of Mental Health for their assistance with this study.
References (72)
- et al.
The moderating role of experiential avoidance in the relationship between posttraumatic stress disorder symptom severity and cannabis dependence
J. Context. Behav. Sci.
(2014) - et al.
An examination of psychiatric comorbidities as a function of gender and substance type within an inpatient substance use treatment program
Drug Alcohol Depend.
(2011) - et al.
Trauma and substance cue reactivity in individuals with comorbid posttraumatic stress disorder and cocaine or alcohol dependence
Drug Alcohol Depend.
(2002) - et al.
Changes in PTSD symptomatology during acute and protracted alcohol and cocaine abstinence
Drug Alcohol Depend.
(2007) - et al.
Amygdala reactivity is inversely related to level of cannabis use in individuals with comorbid cannabis dependence and major depression
Addict. Behav.
(2010) - et al.
The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder
Behav. Ther.
(1995) - et al.
Mini-mental state: a practical method for grading the cognitive state of patients for the clinician
J. Psychiatr. Res.
(1975) - et al.
Medication effects on salivary cortisol: tactics and strategy to minimize impact in behavioral and developmental science
Psychoneuroendocrinology
(2009) - et al.
Beyond the manual: the insider's guide to prolonged exposure therapy for PTSD
Cogn. Behav. Pract.
(2003) - et al.
PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking post-deployment VA health care
Addict. Behav.
(2010)
The functional neuroanatomy of PTSD: a critical review
Prog. Brain Res.
The level of physical activity affects adrenal and cardiovascular reactivity to psychosocial stress
Psychoneuroendocrinology
The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability
Eur. Psychiatry
A preliminary study of cortisol and norepinephrine reactivity to psychosocial stress in borderline personality disorder with high and low dissociation
Psychiatry Res.
A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms
Behav. Ther.
Can the gateway hypothesis, the common liability model and/or, the route of administration model predict initiation of cannabis use during adolescence? A survival analysis—the TRAILS study
J. Adolesc. Health
Triggers for cocaine and alcohol use in the presence and absence of posttraumatic stress disorder
Addict. Behav.
Diagnostic and Statistical Manual of Mental Disorders, (DSM-5)
The Clinician Administered PTSD Scale
Posttraumatic stress disorder and cannabis use characteristics among military veterans with cannabis dependence
Am. J. Addict.
Prospective investigation of the impact of cannabis use disorders on posttraumatic stress disorder symptoms among veterans in residential treatment
Psychol. Trauma
Cannabis use among military veterans after residential treatment for posttraumatic stress disorder
Psychol. Addict. Behav.
Posttraumatic stress, difficulties in emotion regulation, and coping-oriented marijuana use
Cogn. Behav. Ther.
Posttraumatic stress symptom severity predicts marijuana use coping motives among traumatic event-exposed marijuana users
J. Trauma. Stress
Emotional dysregulation: association with coping-oriented marijuana use motives among current marijuana users
Subst. Use Misuse
An evaluation of the nature of marijuana use and its motives among young adult active users
Am. J. Addict.
Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse
J. Am. Psychiatry
Epidemiological investigations: comorbidity of posttraumatic stress disorder and substance use disorder
The awakening cortisol response: methodological issues and significance
Stress
Posttraumatic stress disorder and cannabis use in a nationally representative sample
Psychol. Addict. Behav.
Marijuana, expectancies, and post-traumatic stress symptoms: a preliminary investigation
J. Psychoactive Drugs
Which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects? A survey of traumatic stress professionals
J. Trauma. Stress
Structured Clinical. Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P, Version 2.0)
Unpublished Measure
Emotional processing of fear: exposure to corrective information
Psychol. Bull.
The use of a synthetic cannabinoid in the management of treatment‐resistant nightmares in posttraumatic stress disorder (PTSD)
CNS Neurosci. Ther.
Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States : results from the National Epidemiologic Survey on alcohol and related conditions
Arch. Gen. Psychiatry
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