ANSA Conference, Cairns 24-25 August 2019 Treatment of PTSD and Addiction in Traumatised Adults Mirjana Askovic, ANFI, STARTTS https://poweredtemplate.com/02777/0/index.html
Outline PTSD and substance use disorder/addiction: Epidemiology Refugee trauma Relationship between PTSD and addiction EEG phenotypes and neurofeedback treatment Integrative approach to treatment of trauma and addiction Role of neurofeedback Role of therapist
Epidemiology of PTSD and addiction • The estimated lifetime prevalence of PTSD in the Australian population is 12.2%. Prevalence of PTSD in refugee population is 30% (Still, at al. 2009) • Psychiatric comorbidity, particularly depression, anxiety and substance use disorders commonly occur with PTSD (Gradus, et.al. 2015) • People who suffer from PTSD are between two and four times more likely to also suffer from addiction compared to the general population (Gradus, et. al, 2017) • Among individuals seeking treatment for SUDs, approximately 36% to 50% meet criteria for lifetime PTSD (Brady et.al.2004)
Refugee trauma, PTSD and addiction 8000 7000 6000 5000 NO 4000 YES 3000 2000 1000 0 Sub.Ab/Add
Refugee trauma and addiction Moderate-severe symptoms Substance abuse - YES Substance abuse NO 100 90 80 70 60 50 40 30 20 10 0
Relationship between PTSD and addiction Comorbidity between PTSD and addiction is likely to reflect overlapping environmental, genetic and neurobiological factors. Gene/ Environment Genetics Environment Interaction www.addiction.med.usyd.edu.au
EEG phenotypes and addiction • Jay Gunkelman AND Curtis Cripe looked at the divergent EEG patterns (phenotypes) in addiction (N=30) • Two different neural factors underlie the prevalence of addiction cases, likely representing separate pathophysiologic drives for addictive behaviours: (a) CNS over-arousal (n = 21) (b) cingulate issues/obsessive-compulsive (n = 9) Gunkelman, J. & Cripe, C (2008)
EEG phenotypes and addiction CNS over-arousal based drives were attributed to the following phenotypes: • low-voltage fast EEG phenotype (SMR and A/T training); • faster alpha frequencies (A/T training); • beta spindle (SMR and then A/T). Cingulate-based obsession-and-compulsion–based drives were attributed to anterior midline divergences (Fz supress protocol): • Supress Alpha • Supress Slow (theta) • Supress Beta spindling
Additional EEG patterns and addiction • Third neural factors that underlies the prevalence of addiction cases, likely represents a separate pathophysiologic drive for addictive behaviours related to the addiction to stimulants and compulsive gambling. • Impulsivity has been recognized as a characteristic of individuals addicted to drugs, along with sensation seeking and poor decision making (Ersche et al., 2010) • Neural correlates include amygdala over-responsiveness to reward (Kasanetz et al., 2010) and weakened control of the reflective VMPC (Volkow et al., 2004)
Additional EEG patterns and addiction cont. • EEG in gambling disorder clients with high impulsivity score showed decreased theta absolute power, and decreased alpha and beta absolute power in the left, right, particularly midline frontocentral regions ( Lee et al., 2017). • Neurofeedback protocols focused on midline Fz, Fz-Cz – inhibit slow and reward 12-15hz and higher.
Integrated treatment approaches Integrated Treatment Approaches Mental Addiction Health
Integrative approach to trauma and Integrative approach to trauma and addiction addiction Closure Family system/ deeper issues Relapse Trauma prevention processing Values,beliefs Stabilisation and meaning and affect regulation Contract and committment
Contract and commitment Contract and commitment COMMITMENT RECOGNITION • Regular attendance • Acceptance of the problem • Communication with D&A • Psychoeducation • Building therapeutic alliance • Referral to D&A • Detox TREATMENT PLAN DENIAL • I don’t drink that much • Client’s expectations • Dope is good for your health • Treatment goals • Timeline
Stabilisation and affect regulation Frequently used protocols: C4-A2 Cz-A2/A1 C3-C4 T3-T4 T4-P4 T5-T6 FPO2 Fz-A1
Trauma processing/addiction recovery Alpha/Theta training (Pz-A2) Outline • Guided relaxation • Visualisation of desired outcomes • 40 min A/T • Body scan • Processing of experience • Grounding Role of therapist
Management of relapse Outline
Work with family system/deeper issues Outline
Values, beliefs and meaning sense of belonging orientation re- towards connection future
Relapse prevention and closure SLEEP STRESS EXERCISE MANAGEMENT DIET SOCIAL CONNECTIONS MEANINGFUL ACTIVITIES
Conclusion Relationship between PTSD and addiction Integrated approach to treatment Role of neurofeedback and neuroscience driven approaches Role of psychotherapy/trauma informed therapy
Questions ? ? ? ? ? ?
References 1. Steel Z, Chey T, Silove D et al. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement. JAMA : 302(5) , 537 ‐ 492 (2009). 2. McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. Posttraumatic Stress Disorder and Co-Occurring Substance Use Disorders: Advances in Assessment and Treatment. Clinical psychology : a publication of the Division of Clinical Psychology of the American Psychological Association , 19 (3) , (2012). 3. Gradus, J.L., Antonsen, S., Svensson, E., Lash, T.L., Resick, P.A. and Hansen, J.G. Trauma, comorbidity, and mortality following diagnoses of severe stress and adjustment disorders: a nationwide cohort study. American Journal of epidemiology , 182(5) , 451-458 (2015). 4. Gradus, J.L., Prevalence and prognosis of stress disorders: a review of the epidemiologic literature. Clinical epidemiology, 3 (9) , 251-260 (2017). 5. Brady, K.T., Back S.E. & Coffey S.F. Substance abuse and post traumatic stress disorder. Current direction in psychological science . 13 (5), 206-209 (2004). 6. Rehm, J., Gmel Sr, G.E., Gmel, G., Hasan, O.S., Imtiaz, S., Popova, S., Probst, C., Roerecke, M., Room, R., Samokhvalov, A.V. and Shield, K.D., The relationship between different dimensions of alcohol use and the burden of disease—an update. Addiction , 112(6) , 968-1001 (2017). 7. Lopez ‐ Quintero, C., Hasin, D.S., De Los Cobos, J.P., Pines, A., Wang, S., Grant, B.F. and Blanco, C., Probability and predictors of remission from life ‐ time nicotine, alcohol, cannabis or cocaine dependence: Results from the national epidemiologic survey on alcohol and related conditions. Addiction , 106(3) , 657-669 (2011). 8. Drgon T, D’Addario C, Uhl GR. Linkage disequilibrium, haplotype and association studies of a chromosome 4 GABA receptor gene cluster: candidate gene variants for addictions. Am. J. Med. Genet. B. Neuropsychiatr. Genet , 141B , 854–860 (2006).
References 9. Gunkelman, J. & Cripe, C. (Clinical Outcomes in Addiction: A Neurofeedback Case Series, Biofeedback, 3 6 (4) , 152– 156 (2008). 10. Ersche K.D., Turton A.J., Pradhan S., Bullmore E.T. & Robbins T.W. Drug addiction endophenotypes: impulsive versus sensation-seeking personality traits. Biol Psychiatry . 68(8) , 770-3 (2010). 11. Kasanetz F., Deroche-Gamonet V., Berson N., Balado E., Lafourcade M., Manzoni O. & Piazza V.P. Transition to addiction is associated with a persistent impairment in synaptic plasticity. Science, 328(5986) , 1709-12 ( 2010). 12. Volkow N.D., Fowler J.S., Wang G.J. & Swanson J.M. Dopamine in drug abuse and addiction: results from imaging studies and treatment implications. Mol Psychiatry , 9(6), 557-69 (2004). 13. Lee J.Y., et al. Resting-state EEG activity related to impulsivity in gambling disorder. J Behav Addict , 6(3), 387–395 (2017). 14. Ford J.D. & Russo E. Trauma-Focused, Present-Centered, Emotional Self-Regulation Approach to Integrated Treatment for Posttraumatic Stress and Addiction: Trauma Adaptive Recovery Group Education and Therapy (TARGET). American Journal of Psychotherapy , 60 (4) , 335-355 (2006). 15. Covington S.S. Women and Addiction: A Trauma-Informed Approach, Journal of Psychoactive Drugs , 40(5) , 377-385 (2008). 16. Killeen, T. K., Back, S. E., & Brady, K. T. Implementation of integrated therapies for comorbid post-traumatic stress disorder and substance use disorders in community substance abuse treatment programs. Drug and alcohol review , 34(3), 234–241 (2015).
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