Authored by Cameron Lacy Ortega and Eva Miller*
Abstract
The National Center for Posttraumatic Stress Disorder (PTSD) reported approximately seven to eight people out of 100 will develop PTSD at some point in their lives and an estimated eight million adults will develop PTSD during a given year. It is also estimated between 55-60% of persons diagnosed with PTSD are diagnosed with a substance-use disorder (SUD). However, despite clinical guidelines that increasingly recommend the use of psychotherapies within the same treatment episode for clients with comorbid SUD/PTSD and client preferences for combined PTSD/SUD treatment, clinicians tend to overlook comorbid trauma and substance issues and/or are inclined to provide separate treatment for comorbid trauma and substance-related issues. This review is designed to provide a synopsis of the most effective, evidence-based psychotherapeutic treatments for comorbid PTSD/SUD, with emphasis on recent advancements in mindfulness approaches. The review also discusses ketamine infusion therapy (KIT), a newly developed psychopharmacological approach for treatment-resistant PTSD and comorbid SUD.
Keywords: Posttraumatic stress disorder; Substance use disorder; Psychotherapeutic approaches; Mindfulness; Ketamine infusion therapy
Introduction
The National Center for Posttraumatic Stress Disorder (PTSD) reported approximately seven to eight people out of 100 will develop PTSD at some point in their lives and an estimated eight million adults will develop PTSD during a given year. It is also estimated between 55-60% of persons diagnosed with PTSD are diagnosed with a substance-use disorder (SUD) [1]. However, despite clinical guidelines that increasingly recommend the use of psychotherapies within the same treatment episode for clients with comorbid SUD/PTSD to maximize treatment outcomes [2] and the request from clients for combined treatment for PTSD/SUD, counselors often overlook comorbid trauma and substance issues among their clients and/or they are inclined to provide separate treatment for comorbid trauma and substance-related issues. This review is designed to provide a synopsis of the most effective, evidence-based psychotherapeutic treatments for comorbid PTSD/ SUD, with emphasis on recent advancements in mindfulness approaches. The review also discusses ketamine infusion therapy (KIT), a newly developed psychopharmacological approach for treatment-resistant PTSD and comorbid SUD.
PTSD
PTSD symptoms can develop months to years after the traumatic event occurs and are often chronic, lasting a lifetime. In addition, PTSD frequently results in comorbid issues as a means of coping with the physical and emotional pain associated with PTSD [3], including increased risk for suicide and self [4], relational discord that includes difficulty in the development and maintenance of intimate and trusting relationships (APA), sexual risk-taking, and a range of substance and behavioral [5]. Not all persons exposed to traumatic events will develop PTSD; there are many factors that play a part in whether a person will develop PTSD. These factors include the duration and severity of the trauma, the age of the person at time of exposure to the trauma, as well as resilience factors such as the person’s support system, previously developed coping strategies, and the way the person processes the traumatic [6]. In addition to risk and resilience factors, researchers are looking at genetics and neurobiology as factors associated with the development of PTSD. PTSD memories are stored throughout the brain and research indicates abnormalities in the glutamatergic system in response to stress may be related to PTSD. Specifically, the glutamatergic system is believed to be related to stress/traumaactivated circuits that can lead to glutamate spillover and trigger pro-inflammatory processes and excitotoxicity which, in turn, leads to the onset of PTSD symptoms (e.g. fear reaction, avoidance) [7]. A traumatic experience engages most or all the senses (e.g., sight, hearing, touch/pain). In addition, PTSD affects emotions, speech, and thought. Humans are unique, complex individuals and PTSD manifests differently throughout the population [8] which is one of the myriad of reasons PTSD is hard to treat.
PTSD Treatment
Guidelines have been developed to inform clinicians as to which psychotherapeutic treatments should be considered in clinical practice for PTSD, including the APA (APA, 2017). Said methods are recommended based on strength of evidence, treatment outcomes, patient values and preferences, and applicability of the evidence to various treatment options. The APA panel strongly recommends cognitive processing therapy (CPT) or cognitive behavioral therapy (CBT), prolonged exposure therapy (PET), and eye movement desensitization and reprocessing (EMDR) for treating PTSD. While these recommended treatments have shown efficacy for the treatment of PTSD, neurofeedback and mindfulness therapy are also showing increased efficacy in the treatment of PTSD and comorbid diagnoses such as SUD and depression.
The recommended medications for the treatment of PTSD include fluoxetine, paroxetine, sertraline, and venlafaxine (APA). According to [9], “medications for comorbid PTSD and SUD include the PTSD treatment sertraline, often used in combination with anticonvulsants, antipsychotics, and adrenergic blockers. When PTSD is comorbid with alcohol use disorder (AUD), naltrexone, acamprosate or disulfiram may be combined with PTSD treatments. For PTSD combined with opiate use disorder methadone or buprenorphine are most commonly used with sertraline”.
However, when persons who have PTSD do not respond to psychotherapeutic and/or pharmacological treatments, the risk for development of a chronic course of illness and poor long-term outcomes increase [10]. Individuals diagnosed with PTSD who have failed to respond to established treatment regimens are at risk for the development of a chronic disability and treatment-resistant PTSD (TR-PTSD) is a common barrier in clinical treatment [10]. Emerging research for alternative approaches for TR-PTSD and SUD with the use of ketamine (an analgesic) in conjunction with psychotherapy is beginning to show promising outcomes. The following sections will address current efficacy-based treatments for comorbid PTSD/SUD followed by an overview of new evidence on the efficacy of mindfulness therapy and ketamine therapy for the treatment of comorbid PTSD/SUD.
PTSD/SUD Treatment
Eye movement desensitization and reprocessing (EMDR) treatment suggests pathologies are represented by dysfunctional information that is physiologically stored and can be accessed and transformed directly as opposed to addressing the client’s reaction to the disturbing event as seen in biofeedback, exposure therapies, and relaxation training [11]. EMDR therapy facilitates the accessing and processing of traumatic memories and other adverse life experience to bring these to an adaptive resolution. [12] conducted a study to assess the benefits of a combined trauma-focused (TF) and addiction-focused (AF) EMDR intervention among 40 patients with PTSD/SUD. Of the 40 patients, 20 received treatment as usual (TAU), which consisted of individual and group counseling and psychoeducation on SUD; the other 20 patients were treated with TAU plus EMDR. While both the TAU and the TAU/EMDR groups had a significant effect in reducing post-traumatic symptoms, the EMDR group showed better pre- posttest outcomes. Similarly, [13] added EMDR to a substance abuse treatment program and found the graduation rate for individuals who participated in EMDR was 91% compared to 57% for those who did not participate in the EMDR treatment. [14] also demonstrated efficacy for EMDR over TAU among patients with PTSD/SUD.
Cognitive processing therapy (CPT) typically consists of a 12-session treatment that emphasizes the restructuring of dysfunctional trauma-related cognitions (stuck points) that are postulated as maintaining PTSD symptoms [15] conducted a CPTbased treatment program among 72 veterans and showed veterans reported significant reductions in PTSD symptomatology and significant reductions in trauma-cued cravings and depressive symptoms following the CPT-based treatment. [16] evaluated whether adding trauma-focused treatment following an initial group-based integrated cognitive behavioral treatment improved outcome among 123 veterans with trauma, depression, and SUD. The results were similar for both groups, suggesting CPT is effective in the treatment of comorbid PTSD symptoms, SUD, and depressive symptoms. [17] conducted a case study with a 53-year-old African American female with comorbid PTSD/SUD using an integrated cognitive processing therapy for the PTSD with cognitive-behavioral therapy approach to address SUD (cocaine and alcohol) issues over 12 sessions. The results showed a “clinically significant change” in PTSD symptoms…as well as significant decreases in both cocaine and alcohol use.”
Back et al. (2019) implemented prolonged exposure therapy (PET) involving imaginal and in vivo exposure to trauma-associated stimuli for PTSD among 54 veterans with co-occurring PTSD/ SUD. A control group comprised of 27 veterans received cognitive behavioral therapy (CBT) and relapse prevention (RP) educational training. Results showed a significantly higher proportion of veterans (83%) in the PET group no longer met criteria for PTSD following the training and substance use decreased significantly in both groups, underscoring the efficacy of PET for co-occurring SUD/ PTSD. [18] implemented a similar trauma-focused PET treatment among 71 veterans and CBT/RP educational training among 49 veterans who served as the control group. The results suggested trauma-focused, exposure-based therapy does not increase the risk of symptom exacerbation as compared to non-exposure-based therapy, supporting the efficacy of a combined treatment for PTSD/ SUD. However, studies [19] suggest exposure-based therapy is contraindicated for PTSD and research with populations other than veterans are needed to better understand the efficacy of PTE.
Despite results underscoring the utility of PET, a growing number of studies suggest PET can be deleterious in the treatment of PTSD. For example [19] noted “…exposure to traumatic stimuli is so aversive that a significant number of patients drop-out of therapy during the course of treatment.” (p. 1) Instead, Chiba et al. advocated for the use of neurofeedback “where patients can unconsciously self-regulate brain activity via real-time monitoring and feedback of the EEG or fMRI signals” (p.1) Other studies also provide support for neurofeedback to treat PTSD. For example, [20] conducted a systematic review on the effectiveness of neurofeedback in treating PTSD which was designed specifically for mental health professionals to assess behavioral outcomes. Of the 10 studies that met the criteria for inclusion in the review, the authors concluded neurofeedback demonstrated noteworthy results in at least one outcome measure for many participants across all studies. However, studies on the efficacy of neurofeedback for the treatment of comorbid PTSD/SUD are needed.
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