Alcohol Addiction and Trauma

Kimberly Choiniere, LMSW

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period :1. Tolerance2. Withdrawal3. Larger amounts used over a longer period of use than intended4. Inability to or persistent desire to cut down or control use 5. A great deal of time spent on obtaining, using or recovering6. Important activities given up or reduced7. Use despite problems caused or exacerbated by use with or without physiological dependence

Definition of Substance Dependence (303.90) (DSM-IV-TR)

Alcohol is the most widely used psychoactive drug in the world. Alcoholism is the third leading cause of lifestyle-related death. Approximately 51.5% of adults are current regular drinkers (CDC, 2011). In 2008, 8.5% of adults in the U.S. met criteria for an alcohol use disorder (NESARC). In 2008, more than 12 million Americans suffered from alcoholism and 40-50 million

families were affected (National Library of Medicine, NIAAA, NIH) Approximately 80,000 deaths are attributable to excessive alcohol use each year in the

U.S. (CDC, 2013). Alcohol use is in involved in 83% of homicides, 72% of child violence occurrences, 75%

intimate partner violence, more than 73% of felonies, and 64% of traffic deaths (CDC, NIAAA, and The National Center on Addiction and Substance Abuse, 2008).

In 2010, alcohol-induced deaths, excluding accidents and homicides were 25,692 (CDC). Economic cost of alcohol addiction was an estimated 223.5 billion dollars in 2006 (CDC). Thirty to 80% of suicides are alcohol-related (Murphy, 1992).

Statistics

Substance abuse is a condition influence by biological, psychological, and social factors.

Etiology of Substance Use Disorders

Gender-Alcohol is more common in males, but there is a higher mortality and morbidity rate in females.Memory and attention is more affected in females.

Age- Persons reporting first use of alcohol before the age of 15 are 5 times more likely to report alcohol abuse then people who first used alcohol at age 21 or older. (SAMHSA 2004)

Genetic Heritage-alcohol is highly heritable at 40-60% in first degree relatives (Enoch, Goldman, 1999). Genetics determine vulnerability based on how substances affect an individual brain and behavior (Washton, Zweben, 2008). A variety of genes increase susceptibility and variations in effects on CNS. Genetic susceptibility has been extensively studied (for example, twin studies, adoption studies, and pedigree studies). Temperament and childhood behavior problems play a role in development of alcohol addiction.

Biological Factors: Alcohol is a Complex Brain Disease

Socioeconomic status Prevalence in certain peer groups and

subcultures Religious prohibition against using

psychoactive substances Family Environment, which includes social

learning as well as family systems model

Social Factors

The person using is not using [drugs] to have a problem, they’re using drugs to find a solution” (Vincent Felitti).

At heart, alcoholism feels like the accumulation of dozens of…tiny fears and hungers and rages, dozens of experiences and memories that collect in the bottom of your soul, coalescing over many, many, many drinks into a single liquid solution (Carolyn Knap, Drinking: A Love Story, 1996).

Psychological Factors

Mental, emotional difficulties, cognitive and behavioral problems increase risk of developing alcohol abuse and dependence.

Alcohol is a potent reinforcer alleviating negative affective states (Washton, Zweben, 2008).

Women with anxiety and mood disorders, as well as males with drug abuse and antisocial personality disorder are more prone to alcohol dependence development.

Psychological Factors

12 ounces of regular beer 5 ounces of wine 1.5 ounces of 80-proof distilled spirits

(whiskey, vodka)

Measurements: How do you determine a standard drink?

Dosage determines action on the body. At low doses, alcohol acts as a disinhibitor

increasing euphoria. At higher doses, alcohol can lead to sleep or

coma, and even death by respiratory distress.

How Alcohol Affects the Body

Alcohol is measured by the number of grams present in 100 milliliters of blood expressed as a percentage.

Limited effects- 0.03% Slowed reactions- 0.05% Slurred speech and impaired motor

coordination-.10-.15% Loss of consciousness- .30% Death- 40%

Blood Alcohol Concentration

Alcohol is absorbed directly into the blood stream from the gastrointestinal tract.

Alcohol is the only drug absorbed by every cell in your body.

Alcohol affects all brain functions including behavior, respiration, psychomotor, coordination, sexuality.

How Alcohol Affects the Body

Immediate Effects: unintentional injury, including violence, risky sexual behavior, miscarriage, stillbirth, and alcohol poisoning

Long-Term Effects: Neurological (stroke, dementia, neuropathy), cardiovascular (MI, cardiomyopathy, atrial fibrillation, hypertension), cancer (mouth, esophagus, liver, colon, breast), liver disease (alcoholic hepatitis, cirrhosis, fatty liver, fibrosis), pancreatitis, gastritis, immune system dysfunction (increased risk of TB and pneumonia), malnutrition, brain cell damage, Wernicke-Korsakoff Syndrome

Effects of Alcohol Abuse

Memory lapses after heavy drinking Needing more alcohol to feel “drunk” Alcohol withdrawal symptoms when you

haven’t had a drink for a while Alcohol-related illnesses May often drink alone, become violent, make

excuses for drinking, hide use, miss work, continue despite negative consequences

Symptoms of Dependence

Experimental Use- few exposures which might be precipitated by curiosity

Occasional/Irregular Use- modest amounts used infrequently

Circumstantial Use- specific social situations

Binge Use-large amounts over a short period of time (on average two hours) (most common form of excessive consumption). Binge use is four or more drinks consumed by females and five or more by males.

Abuse- medicinal preoccupation

Dependence- chronic use which may result in death

Patterns of Use

Questions asked in a non-confrontational direct manner- Why now?

Substance use quantity Substance use frequency Nature and extent of use Assess for alcohol-related problems (medical, behavioral,

psychological)

Screening for Alcohol Problems: The Structured Interview

Quantity-Frequency MethodsDrinking Self-Monitoring Logs (daily diary for two weeks)Prompted Daily Recall and Timeline Methods (calendars, charts to collect information on specific dates or days)

Self-Administered Questionnaires for level and pattern of use

CAGE (Buchsbaum, Buchanan, Centor, Schnoll, & Lawton, 199; Soderstrom, Smith, Kufera, Dischinger, Hebel, & McDuff, et al., 1997)

Alcohol Use Disorders Identification Test (AUDIT) (WHO, 1997)

T-ACE (Sokol, Martier, & Ager, 1989) and TWEAK (Russell, Martier, Sokol, Mudar, Bottoms, & Jacobson, et al., 1994)

CHARM (Sumnicht, 1991)

Screening Tools for Alcohol Use Problems

C: Cutting DownA: AnnoyanceG: GuiltE: Eye Opener(Buchsbaum, Buchanan, Centor, Schnoll, & Lawton, 1991; Soderstrom, Smith, Kufera, Dischinger, Hebel, & McDuff, et al., 1997)

CAGE Instrument

1. Have you ever felt that you should cut down on your drinking?2. Have people annoyed you by criticizing your drinking?3. Have you ever felt bad or guilty about your drinking?4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

CAGE Instrument

Brief Drinker Profile (Miller & Marlatt, 1984) Structural Interview for DSM IV-TR (First, et al.,

2001) Basic-Quantity Frequency Items (NIAAA, 1995) Alcohol Dependence Scale (Skinner and Horn,

1984) Drinker Inventory of Consequences (Miller,

Tonigan, and Longabaugh, 1995)

Alcohol Problem Assessment

Typical Pattern of Use Episodic occasions of use Time span of consumption, allowing

estimates of peak and typical BAL’S achieved

(Miller, Marlatt, 1984)

Brief Drinker Profile

Stage 1: Pre-contemplation (not ready with no intention to change within the next six months)

Stage 2: Contemplation (may be ready with the intention to change within six months)

Stage 3: Preparation (ready to change within 30 days)

Stage 4: Action

Stage 5: Maintenance (Prochaska & DiClemente, 1982)

Stages of Change: Readiness of Change Assessment

Usually within 24-48 hours after cessation Mild symptoms include tremor, insomnia, sweating,

weakness, nausea, vomiting Severe and potentially life-threatening delirium tremens can

occur if heavy drinker ceases use abruptly without medications.

DTS can include extreme agitation, anxiety, profound depression and lethargy, increasing mental confusion, profuse sweating, elevated pulse rate, rise in body temperature (Washton, Zweben, 2008).

Alcohol Withdrawal

Naltrexone/ Depade/ReVia/Vivitrol Acamprosate/Campral Disulfram/Antabuse Gabapentin/Neurontin in current study

(NIAAA, NIH, 2013)

Medications for Treating Alcohol Dependence

Substance abuse and dependence combined into single substance use disorder

Specific to substance Found within addictions and related

disorders

DSM-V Proposed Changes to Substance Dependence

Trauma is a stress that causes physical and emotional harm from which you cannot remove yourself (Larke Huang, Office of Behavioral Health Care Equity, SAMHSA).

Trauma is a stress resulting from exposure to, or witnessing of events that are severe and/or life threatening (American Psychological Association).

Trauma and Addiction

The person has been exposed to a traumatic event in which the person experienced , witnessed or were confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self and others and the person’s response involved intense fear, helplessness and horror.

DSM IV Definition of PTSD

The traumatic event is persistently reexperienced, in one or more ways (examples include recurrent distressing dreams and intrusive thoughts and recollections)

There is persistent avoidance of stimuli associated with the trauma and numbing in three or more areas (examples include detachment and markedly diminished interest in significant activities)

Persistent symptoms of increased arousal in two or more areas (examples include hypervigilance and difficulty falling asleep)

Duration is more than a month The disturbance causes clinically significant distress, or impairment

in social, occupational, or other important areas of functioning

DSM-IV Definition cont’d:

Natural Crises- tornadoes, earthquakes, tsunamis

Manmade Disasters- war, genocide, homicide, abuse, neglect, assault, witnessing the abuse of others

Personal Loss-death, health trauma, disability, accidents

Etiology of Trauma

Ground Zero Study- 10 middle and high school students

Exposures to trauma included proximity of school to WTC, perceived fear, loss of loved one, fear for loved ones safety

With three or more exposures, children were 19x more likely to have increased use of alcohol and drugs.

Rates in Specific Samples

Identified correlations between severe childhood stress and various addictions

Found that the effects of trauma are cumulative and identified adverse experiences as abuse, neglect, divorce, death, domestic violence, and/or having a mentally ill or addicted parent.

Boys in the sample with four or more adverse experiences were five times more likely to become an alcoholic.

The Adverse Childhood Experiences Study (ACE)

Rate of physical abuse in alcoholics: 24% males and 33% females

Rate of sexual abuse in alcoholics: 12% males and 49% of females

Added long-term consequences are increased rates of depression, anxiety, suicide, and behavioral disorders

Alcoholism Clinical Experimental Research Study (2012)

Traumatic events produce profound and lasting changes in physiological arousal, emotion, cognition and memory (Herman, 1992)

Profound and Lasting Changes

Physical-increased blood flow, increased heart rate, increase in adrenalin, fluctuations in blood pressure

Affective-anxiety, numbness, fear, survivor’s guilt Cognitive- poor attention span, obsessive

thoughts, nightmares, flashbacks Behavioral- sleep disturbances isolation, fatigue,

irritability, including substance abuse

Reactions to Trauma

Trauma victims attempt to control internal states of hyperarousal, social withdrawal, emotional pain and anger through the use of substances (Van Der Kolk,1994).

Increased rates of specific medical problems seen in trauma survivors include hypertension, chronic pain disorders, heart disease, gastrointestinal disorders, HIV risk, and mortality.

Additional Considerations

MDD and dysthymia Anxiety Disorders Psychotic Disorders Borderline and Antisocial Personality

Disorders Dissociative Disorders

Other Co-Occuring Disorders

Self-Administered Post-Traumatic Diagnosis Scale (Coffey et al., 1998)

Impact of Events Scale-Revised Davidson Traumatic Stress Scale PTSD Checklist (Weathers, 1993)

Diagnostic Tools

Checklist: 17-item self-report screens, diagnoses, monitors symptoms

CAPS (Clinician Administered PTSD Scale):30-item structured interview that addresses 17 symptoms and consists of a Life Events Checklist (Blake, Weathers, Nagy, Kaloupek, Charney and Kearne, 1995)

PTSD Checklist and CAPS

SSRIS SSNRIS TCAS MAOIS Mood-stabilizing anticonvulsants Atypical antipsychotics Anti-adrenergic agents

Pharmacotherapy for Dual-Diagnosis

Seeking Safety (Najavits,1992) Trauma Recovery and Empowerment Model

(TREM) (Harris, 1998) Addiction and Trauma Recovery Integration

Model (ATRIUM) (Miller, 1994)

Trauma-Informed Approach

Based on cognitive-behavioral and relational theories

Addresses mind, body, spirit 12 weeks Group setting Peer or professionally facilitated

ATRIUM Model

Introduces a preschool subtype for PTSD for children six years and younger

New specification includes a dissociative subtype Removal of requirement that one needs to

experience fear, helpless, or horror in response to a traumatic event

Avoidance symptoms will be separated into two different clusters

DSM-V Changes to PTSD