Implications for Treatment of PTSD and Alcoholism

by National Institute of Health

(Page 4 of 4)

The treatment of PTSD patients with alcohol dependence involves simultaneously addressing both disorders, because they seem to be intertwined. In therapy, patients learn to cope with their previous traumas and to handle situations that may remind them of the event. In this way, the patients learn how to better control or avoid such situations. Because research shows that both alcohol use and trauma increase endorphin activity, opioid receptor blockers may be a useful part of treatment for PTSD. We speculate that as trauma-related memories brought up during therapy may cause a release of endorphins and subsequent emotional numbing, this may interfere with the patient's ability to engage in therapy fully. We also speculate that as endorphin levels decrease after the therapy session ends, endorphin withdrawal may lead to increased alcohol craving. Although alcohol use may temporarily relieve PTSD symptoms, alcohol withdrawal intensifies such symptoms. To avoid the increase in PTSD symptoms following a bout of drinking, the patient is caught in a vicious cycle in which he or she must continue to drink to avoid the unpleasant reaction following an alcoholic binge. An opioid antagonist such as a naltrexone would block the endorphin response and reduce the desire for alcohol. In an animal study, we have shown that the opioid blocker naltrexone can prevent increased alcohol consumption following trauma. Rats will typically increase their alcohol consumption after several days of 1-hour sessions of brief electric footshocks. However, the use of naltrexone effectively blocked the poststress increase in alcohol drinking. Administering naltrexone as part of the treatment for patients with both PTSD and alcoholism may help break the addictive cycle.

Margaret sought treatment from an alcoholism treatment provider after yet another extended bout with heavy drinking left her physically exhausted. During her initial evaluation, she was diagnosed with PTSD for the first time. She was referred for pharmacotherapy with naltrexone and concomitant psychotherapy using prolonged exposure, which was modified to include a focus on the functional relationship between PTSD symptoms and drinking. Prolonged exposure involves repeated, prolonged, imaginal exposure to the trauma memory or memories that arise during therapy. The patient is encouraged to relive the traumatic memory as vividly as possible, with the goal of allowing greater access to the emotional and cognitive content of the memory (which is actively avoided by individuals with PTSD) to facilitate emotional processing and integration of the experience. During treatment, the role of avoidance in the maintenance of PTSD was explained to Margaret, and she was encouraged to confront her traumatic past through prolonged, systematic exposure to the memories and to gradually confront the situations she had been avoiding in her daily life. During discussions of her exposure exercises, Margaret became more aware of the frequent association between her reexperiencing symptoms and her urges to drink, which through the combination of medication and the development of less avoidant coping strategies, she was generally able to resist. Over a three-month course of treatment, Margaret exhibited progressively less distress during imagined exposure, her memories for the traumatic events gradually became less disjointed, and she eventually expressed a sense of resolution regarding these events. Although Margaret appeared resistant to treatment at several points by canceling or avoiding sessions, and although she experienced two significant drinking bouts during the early stages of therapy, with the support of her therapist Margaret's symptoms eventually diminished to the point where she could no longer be diagnosed with PTSD. As a result, she felt much more capable of combating temptations to drink, which she continued to encounter from a variety of triggers not related to PTSD. At the end of treatment, Margaret stated that for the first time in her life she felt "free" and truly able to put her past behind her. Margaret was encouraged to maintain contact with her treatment providers for continued support to help maintain her gains and cope with setbacks.

Summary

Uncontrollable trauma in animals and humans leads to stress-induced increases in the release of endorphins. The emotional numbing seen in rats exhibiting learned helplessness and in patients with PTSD may be related to the increased release of endorphins as a result of stress. Such increases in endorphin activity are observed in response to trauma and may also occur during exposure to trauma reminders. Afterward, a period of endorphin withdrawal may explain the physiological hyperactivity, depression, and irritability that mark patients with PTSD. This endorphin withdrawal can be reduced by alcohol use. This model has two important implications for the treatment of PTSD and alcoholism. First, therapy aimed at increasing one's sense of mastery over traumatic events can help patients cope when exposed to trauma reminders. By reversing feelings of helplessness, one can more easily recover from PTSD and related alcohol problems. Second, the use of opioid blockers such as naltrexone may block the effects of alcohol and break the addictive cycle.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.