Many individuals who abuse cocaine, alcohol, and other substances also suffer from posttraumatic stress disorder (PTSD) related to life-threatening or other traumatic events they have experienced or witnessed. Individuals with PTSD suffer recurring flashbacks, anxiety, and other symptoms that can impede substance abuse treatment. Similarly, substance abuse can make PTSD symptoms worse. Thus, integrated treatment is recommended as the way to treat patients with both disorders. Yet until recently, the most effective nonpharmacological treatment for PTSD, known as exposure therapy, was considered too risky to use with cocaine-dependent patients. The therapy seeks to desensitize patients to the distressing emotional effects of the trauma that triggered their PTSD by requiring them to repeatedly and graphically describe it.

Combination Psychotherapy Reduces Posttraumatic Stress Disorder (PTSD) Symptoms and Cocaine Use Fifteen cocaine-dependent patients with PTSD who completed a psychotherapy that addressed both disorders significantly reduced cocaine use and had fewer and less intense PTSD symptoms, as assessed by physicians.

"Researchers and clinicians have been reluctant to use exposure therapy with cocaine-dependent patients," says Dr. Kathleen Brady of the Medical University of South Carolina in Charleston. "Drug abuse patients were thought to be likely to turn to alcohol and drugs to cope with the emotional demands placed on them by recounting the fear-inducing experience."

A preliminary study led by Dr. Brady suggests that the belief that exposure therapy would do these patients more harm than good may not be merited. In the study, instead of triggering emotional distress and relapse to substance abuse, treatment that combined exposure therapy for PTSD with substance abuse counseling produced substantial improvement in both disorders.

Thirty-nine cocaine-dependent individuals with PTSD, 32 of them women, participated in the outpatient study. The majority of participants had developed PTSD following such severe traumatic experiences as rape (74 percent), aggravated assault (89 percent), and other physical assault (95 percent). Individuals who feel intense fear and helplessness or horror during such terrifying events can later develop distressing symptoms that can impair their ability to live and work normally.

PTSD symptoms fall into three general categories: "intrusions," such as flashbacks or nightmares in which the person reexperiences the traumatic event; "hyperarousal" or anxiety, which can be marked by extreme vigilance and jumpiness, difficulty sleeping or concentrating, and irritability; and "avoidance" of people, activities, and situations that might trigger memories of the incident. When symptoms persist for more than 3 months, PTSD is considered chronic. Chronic sufferers often have additional psychiatric disorders. An estimated 30 to 60 percent of individuals with substance abuse disorders have PTSD, according to studies cited by Dr. Brady.

The study used a psychotherapy developed by Dr. Brady and her colleagues that combines counseling for drug abuse with exposure therapy for PTSD. "We wanted to evaluate whether cocaine-dependent PTSD patients could safely tolerate the therapy and whether it would be effective in reducing the severity of their PTSD symptoms and cocaine use," Dr. Brady says. The combined therapy consists of 16 90-minute individual sessions. In the first 3 weeks, patients participate in two counseling sessions a week that concentrate solely on their drug abuse problems and developing relapse prevention skills. "The therapy in those first sessions gives people a chance to experience some sobriety and provides them the coping techniques and strategies they will need to deal with high-risk situations and the urges to use drugs they may experience when they get into the exposure therapy," Dr. Brady says.

Once patients start to feel comfortable sharing their feelings with the therapist and are willing to engage in exposure therapy, a technique called imaginal exposure is used to address their PTSD symptoms. In imaginal sessions, patients describe in detail the circumstances and feelings they experienced during the traumatic event that triggered their disorder. They also develop a list of situations or places they have been avoiding because they associate them with the event. Between sessions, patients carry out assignments in which they gradually expose themselves to similar situations that are safe but fear-inducing. If, for example, they were abducted from a parking lot and assaulted, they may have become fearful of any parking lot or areas with cars in them. Assignments could involve going to such areas, first with a friend, then by themselves in the middle of the day.

"We are trying to get at the irrational fears and inappropriate avoidance of situations that are interfering with their lives," Dr. Brady says. "By talking about their experience over and over in the imaginal sessions, they are basically reliving it. The point of the exposure is to desensitize them to the trauma, thereby reducing the fear, anxiety, and emotion from the memory itself. By the end of successful therapy, patients are able to go through their entire traumatic scenario and feel much less distressed because they are able to separate irrational fears from simply thinking about the event."

The goal of the therapy is that the intrusion, arousal, and avoidance symptoms all recede. The exposure has done its job when someone can go through his or her detailed recalling of the event and score no higher than 5 on a 20-point scale that measures how much distress they are feeling, says Dr. Brady.

Fifteen of the 39 study participants completed the combined therapy, attending at least 10 of the 16 sessions, including a minimum of 3 exposure therapy sessions. Assessments by both patients and clinicians indicated that those who completed treatment experienced significant reductions in all three PTSD symptom categories and in cocaine use from study entry to treatment completion.

Using a self-administered Impact of Events Scale, patients reported a 53-percent reduction in "intrusion" symptoms and a 27-percent reduction in inappropriate avoidance behaviors. Over the same period, clinicians using a 30-item structured clinical interview tallied a 66-percent reduction in "intrusions," a 70-percent reduction in "avoidances," and a 47-percent reduction in hyperarousal symptoms. By the end of treatment, completers also had reduced cocaine use by 60 percent and reported experiencing significantly fewer substance-related problems. Followup assessments indicated that treatment completers had maintained these improvements in both PTSD symptoms and cocaine use 6 months after treatment ended. In contrast, no differences emerged in any PTSD or substance-abuse-related scores at treatment completion or 6 months later among noncompleters.

"This study provides promising preliminary evidence that exposure therapy can be used safely and effectively in treating PTSD in some cocaine-dependent individuals without increasing the risk of relapse," says Dr. Brady. The improvements in PTSD symptoms were comparable to those reported by other studies that used exposure therapies to treat patients with no substance abuse disorder. Dropout rates, though high, also were similar to those in previous studies that used other psychotherapies to treat cocaine-dependent patients.

Nevertheless, the small number of patients in the study and the high dropout rates underscore the need for randomized controlled studies to replicate these results, Dr. Brady cautions. Such studies also could provide information that would help to identify patients who are likely to benefit from this treatment, as well as those who might need different approaches.

Source

Brady, K.T., et al. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings. Journal of Substance Abuse Treatment 21(1):47-54, 2001.

Volume 18, Number 1 (June 2003)