Concurrent treatment of posttraumatic stress disorder and alcohol dependence: Predictors and moderators of outcome.

Abstract

Objective The present study examined predictors and moderators of treatment response among 165 adults meeting DSM-IV criteria for comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD) who were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive counseling for alcohol use. Method Six domains of predictors/moderators (23 variables) were evaluated using measures of PTSD (Posttraumatic Stress Symptom Scale Interview; PSS-I) and AD (percent days drinking from the Timeline Follow-Back Interview) collected every four weeks throughout treatment. Multi-level modeling using the Fournier approach was employed to evaluate predictors and moderators of rates of symptom improvement and post-treatment outcomes. Results Combat trauma, sexual assault trauma, and higher baseline anxiety sensitivity predicted slower improvement and poorer PTSD outcome. Combat trauma, white race, and higher baseline drinking severity predicted poorer drinking outcome. PTSD severity moderated the efficacy of PE on PTSD outcomes, such that the benefit of PE over no-PE was greater for participants with higher baseline PTSD severity. Baseline depressive severity moderated the efficacy of PE on drinking outcomes, whereby the benefit of PE over no-PE was greater for participants with higher depressive symptoms. NAL effects were most beneficial for those with the longest duration of alcohol dependence. Conclusions These results suggest that concurrent, trauma-focused treatment should be recommended for PTSD-AD patients who present with moderate or severe baseline PTSD and depressive symptoms. Future research should examine the mechanisms underlying poorer outcome among identified sub-groups of PTSD-AD patients.

Exercise Augmentation of Exposure Therapy for PTSD: Rationale and Pilot Efficacy Data

“…The PE pre- and post-PSSI means were 37.00 and 8.25, respectively, and the PE + E pre- and post-PSSI means were 42.00 and 5.20, respectively. The dashed line in Figure 2 denotes the good end-state functioning cut-off (PSSI ≤10; Powers et al, 2012; Zandberg et al, under review). Because the sample size in this pilot trial was too small to conduct traditional significance tests, we computed between-group effect sizes (i.e., controlled Cohen's d ) of pre- to post-treatment changes in the putative mediator and outcome (see Figure 3).…”

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters

“…It is possible that because accidents and “other trauma” types are not as widely recognized as potential precursors to PTSD as sexual assault, physical assault, or combat, patients who have experienced these traumas may view themselves differently in terms of their PTSD status or need for ongoing PTSD treatment. Interestingly, findings from the same RCT demonstrated a predictive relationship between trauma type and treatment outcome, such that sexual assault was associated with worse PTSD outcomes, and combat trauma was associated with worse PTSD and drinking outcomes (Zandberg et al, 2016). This suggests that the types of trauma associated with dropout risk are different than those associated with attenuated treatment response.…”

The role of anxiety sensitivity in reactivity to trauma cues in treatment-seeking adults with substance use disorders

“…Moreover, it is not possible to determine if either trauma exposure or the development of PTSD was associated with an increase in anxiety sensitivity. However, findings that anxiety sensitivity predicts the onset of anxiety disorders [21, 22] and PTSD symptoms [23–25], and is relatively stable over time [78, 79] somewhat mitigate this concern. It also warrants consideration that our diagnostic interview for PTSD was designed to assess DSM-IV diagnostic criteria for PTSD.…”

“…Anxiety sensitivity is prospectively associated with the onset of anxiety disorders [21, 22], as well as the experience of PTSD symptoms [23–25]. In addition, individuals with PTSD exhibit elevated levels of anxiety sensitivity [26], and higher anxiety sensitivity is linked to greater PTSD symptom severity and posttraumatic distress following trauma exposure [27, 28].…”

“…Higher anxiety sensitivity has also been linked to greater PTSD severity in cocaine-dependent adults [34] and worse treatment outcomes among those with co-occurring PTSD and alcohol dependence [25]. Furthermore, although much of the research on anxiety sensitivity and substance use has utilized nonclinical or unselected samples, anxiety sensitivity has been linked to a number of negative substance use-related outcomes, including alcohol problems among current drinkers [35], treatment dropout among patients with cocaine dependence [36], and benzodiazepine misuse in patients with opioid use disorder [37].…”