Short communicationCharacterization of comorbid PTSD in treatment-seeking alcohol dependent inpatients: Severity and personality trait differences
Introduction
Alcohol consumption causes approximately 9.6% of disability-adjusted total life years lost and is the fifth leading cause of death (Whiteford et al., 2013). Alcohol abuse can lead to the development of AD and associated cancer, liver cirrhosis, and suicide (National Institute on Alcohol Abuse and Alcoholism, 2012). AD heterogeneity necessitates targeted interventions (Litten et al., 2015).
Despite frequent AD comorbidity, alcohol treatment and research often focus on AD alone (Berenz and Coffey, 2012). PTSD is often comorbid with AD (AD/PTSD+); among those diagnosed with PTSD, 41.8% also have a lifetime diagnosis of alcohol abuse or dependence (Pietrzak et al., 2011). In 2012, President Obama issued an Executive Order directing the Department of Defense (DoD), Veterans Affairs (VA), and Health and Human Services (HHS) to develop a National Research Action Plan (NRAP) for PTSD and other mental health conditions to address the needs of a military that has been deployed in on-going wars since 2001 (Executive Order No. 13625, 77C.F.R. 54783, 2012). In response, the NRAP specifically targets increasing research on PTSD and comorbid AD and substance use disorders (SUD) emphasizing prevention and treatment development (Department of Defense et al., 2013).
Clinical practice guidelines (CPG) recognize integrated treatment options for AD/PTSD+, but offer incomplete advice on concurrent treatment and conclude that further research is needed (The Management of Post-Traumatic Stress Disorder Working Group, 2010, Work Group on Substance Use Disorders American Psychiatric Association, 2006). A recent review and meta-analysis found that treating comorbid substance dependence and PTSD concurrently, possibly including naltrexone for AD (Foa et al., 2013), led to a decrease in PTSD symptoms with no worsening of substance use (Roberts et al., 2015).
A 2010 review found that individuals with AD/PTSD+ had more severe PTSD symptoms and were more prone to alcohol use relapse than those with either disorder alone (McCarthy and Petrakis, 2010). Jacobsen et al. (2001) review also supports a functional association between PTSD and AD. AD and PTSD interact and produce worse outcomes than either disorder alone (Berenz and Coffey, 2012), further complicating treatment. Treating these disorders separately does not address possible common mechanisms and pathways (Logrip et al., 2012, Norman et al., 2012), leading to poorer prognosis (Berenz and Coffey, 2012). Further, McCarthy and Petrakis (2010) found that interventions targeting the symptoms of comorbid PTSD and AD were most effective. Clinical treatment would benefit from further exploration of characteristics that distinguish treatment-seeking inpatients with AD/PTSD+ from those with AD/PTSD-.
Recent research has focused on personality factors in alcohol use. Neuroticism is linked to anger, anxiety, depressed mood, and irritability (Barlow et al., 2014), substance use disorders (Valero et al., 2014), higher substance use relapse rates (Fisher et al., 1998), and PTSD (Cox et al., 2004). It is not known whether this association with neuroticism will be observed in a population of individuals with AD/PTSD+. The purpose of this study is to explore this potential association and inform treatment for those with AD/PTSD+.
We explored whether an association between PTSD and alcohol use/dependence would be observed in a large and unique inpatient population with severe AD in a highly controlled research hospital. We hypothesized that inpatients with AD/PTSD+ would have higher levels of alcohol use and dependence than AD/PTSD-. Consistent with Boschloo et al. (2013) finding that depressive/anxiety disorders predict the onset of AD and vice versa, we also hypothesized that inpatients with AD/PTSD+ would have greater rates of anxiety and mood disorders. Finally, we explored whether inpatients with AD/PTSD+ had more neuroticism and/or aggression.
Section snippets
Participants
Participants who met the Diagnostic and Statistical Manual for Mental disorders, 4th Edition, Text-revised (DSM-IV-TR; American Psychiatric Association, 2000) criteria for alcohol dependence were consecutively voluntarily admitted from 2005 to 2009 to the National Institute on Alcohol Abuse and Alcoholism Inpatient Unit in the NIH Clinical Center. Participants were literate in English and were not suffering from active psychotic symptoms or cognitive impairment. They were routinely queried
Demographics and alcohol consumption
Demographic and drinking data are summarized in Table 1. Participants reported drinking approximately 14 drinks per drinking day in the 90 days preceding admission. The two groups did not differ on number of drinks, drinking days, or drinks per drinking day. However, AD/PTSD+ participants had a greater severity of AD, with a moderate effect size. There was no between-group difference in peak CIWA-Ar scores, F[1, 279] = 0.07, p = 0.80, or CIWA-Ar scores on days 1 and 2 (p = 0.57) (not shown in table).
Anxiety and depression
Discussion
This study compared AD/PTSD+ and AD/PTSD- on drinking, psychiatric symptoms, personality, and functioning. Participants with AD/PTSD+ did not report heavier alcohol consumption than those with AD/PTSD- in the ninety days before the study, nor did they report higher scores on the alcohol withdrawal scale. Interestingly, however, they did report higher level of dependence, with a moderate effect size. However, the relationship between PTSD and drinking is clearer in individuals without AD, with
Conflict of interest
No conflict declared.
Role of funding source
Nothing declared.
Author contributions
Ms. Sells was the lead investigator for analysis and manuscript development. Dr. Waters assisted with analysis and manuscript development. Dr. Schwandt was an associate investigator in charge of data management and curation. Dr. Kwako assisted with manuscript development. Dr. Heilig was an associate investigator and assisted with manuscript development, Dr. George was the principal investigator of the clinical protocol and provided patient care and assisted with manuscript development. Dr.
Acknowledgements
The authors gratefully acknowledge the NIH Clinical Center Alcohol Clinic and 1-SE Inpatient behavioral health unit, and Dolores Elliot, David Herion, John Umhau, and the late Dan Hommer for clinical support, and the study participants for their participation in the study. Special thanks to the laboratory research staff, in particular Betsy Davis, Linda Doty, Debby Hill, Cheryl Jones, Mike Kerich, Monte Phillips, and Dena Stringer, as well as current and former intramural fellows.
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