Yale Psychiatry Grand Rounds: February 5, 2021

February 05, 2021

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"Comfortably Numb: Research on the Etiology and Treatment of Comorbid PTSD and Alcohol Use Disorders"

Debra Kaysen, PhD, Professor of Psychiatry and Behavioral Sciences (Public Mental Health & Population Sciences), Stanford University Medical Center

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00:00Maybe?
00:07Very welcome to visiting lecture
00:09series Grand Round series today
00:12we're thrilled to have Professor
00:14Cason from Stanford with US, and.
00:18Doctor teams will introduce her in
00:21just a minute. I just wanted to.
00:28Thank everybody for thoughtful feedback
00:31about our prior grand rounds presentation.
00:34An and kind of a lively and really
00:39important discussion about about the
00:42presentation from Doctor Sattel.
00:45And with feedback that we've received
00:48where taking a number of steps,
00:51including looking at the composition of
00:54the visiting Lecture Series Committee and
00:58some of the practices of that committee.
01:01I think these changes will be very
01:04helpful for our Department. In the.
01:08Hoping our grand rounds venue be
01:11even more reflective of the efforts
01:15of our Department to develop.
01:18Community. But that is both diverse,
01:23equitable and inclusive,
01:24so I just want to thank everybody for
01:28the feedback that we received and.
01:31And with that Jack, once you take it away.
01:37Thanks John.
01:39I'm very pleased today to welcome
01:41Doctor Deborah Case and to give the
01:43annual lecture for the Division of
01:45Prevention and Community Research
01:47in the Department of Psychiatry.
01:48Doctor Cason is professor of
01:50psychiatry and behavioral Sciences
01:52in the section on bubbled mental
01:54health and population Sciences at the
01:56Stanford University Medical Center.
01:58She's leading researcher on the
02:00Inter relationship of trauma,
02:01PTSD and alcohol use.
02:03Doctor Kayson received her PhD
02:05in clinical psychology from the
02:07University of Missouri and completed
02:09a clinical internship and postdoc
02:11at the University of Washington.
02:13She then joined the Washington faculty
02:15in the Department of Psychiatry and
02:17Behavioral Sciences and founded a
02:19program to develop and test more
02:22iaccessible interventions for
02:23individuals with mental health
02:25symptoms following trauma in 2019,
02:26Doctor Cason joined the Stanford faculty.
02:30Doctor Caseness conducted critical
02:31studies on the treatment of PTSD and
02:34or substance use across a variety
02:37of populations.
02:38Sexual minority women, Native Americans,
02:40sexual assault survivors,
02:41torture survivors, active duty military,
02:43and in a variety of settings,
02:45such as in primary care,
02:48rural communities, an internationally,
02:50her research on PTSD and substance
02:53use is also focused on understanding
02:55how PTSD and substance use may
02:57influence one another.
02:59Doctor Kacian is the author of over
03:01130 publications and her research has
03:03been funded by the National Institute
03:05of Alcohol Abuse and Alcoholism,
03:08National Institute on Drug Abuse,
03:10National Institute on Minority
03:11Health and Health Disparities,
03:13the Department of Defense, Aquarian USAID.
03:15She is also the immediate past
03:17president of the International
03:19Society for Traumatic Stress Studies
03:20and a Fellow of the Association for
03:23Behavioral in Cognitive Therapies.
03:25The title of her talk today
03:27is comfortably numb.
03:29Research on the etiology and treatment of
03:32comorbid PTSD and alcohol use disorders.
03:35Doctor kayson
03:37thank you so much for that lovely
03:40introduction and thank you all for
03:42inviting me and for giving me a little
03:44bit of your time for this conversation.
03:47So just to start us off,
03:49I want to contextualize PTSD an why
03:51my career is focused on this around 40
03:54to 90% of Americans have experienced
03:57dramatic stress things like car accidents,
03:59assault, child abuse and combat.
04:01At some point during their lives,
04:03about 20% have experienced a
04:05traumatic event within the past year.
04:08And about 25 million Americans have
04:10PTSD and that was pre pandemic.
04:12Left untreated,
04:13about half of those with PTSD don't recover.
04:17In 2000, PTSD was estimated to cost
04:20the US economy about $40 billion per
04:23year and increased healthcare costs,
04:25decreased worker productivity
04:26and prescription drug costs.
04:28So this is a very expensive
04:30illness for us as a society.
04:33When we look beyond the United States,
04:35traumatic events and associated mental
04:37health consequences are a major contributor
04:39to the global Burden of Disease.
04:44So, just briefly, in terms of disclosures,
04:46I do have a commercial disclosures.
04:48I have consulted as a Advisory Board
04:50member for Jazz Pharmaceuticals.
04:52I also have a book published on
04:55Cognitive Processing Therapy from
04:56Elsevier that in theory someday I
04:58will receive royalties from and I do
05:01occasionally receive honorarium for
05:02conducting workshops or trainings on
05:04fighting their processing therapy.
05:06When I remember to build people
05:08for having done the training.
05:11Mom, I also want to thank all
05:14of my collaborators.
05:15This body of work that I'm going to be
05:17talking about today really has taken a
05:20village of wonderful smart collaborators,
05:22many of whom are far smarter than I am,
05:25and I want to thank my Thunder.
05:27Is that the National Institutes of
05:29Alcohol Abuse and Alcoholism and the
05:32National Institutes of Drug Abuse?
05:36But when we talk about PTSD,
05:38PTSD is far more likely to present
05:41with comorbidity than by itself,
05:43so respondents with PTSD or substantially
05:46more likely to develop their anxiety,
05:48mood, and substance disorders
05:50than those without PTSD.
05:52And what's interesting is this
05:54is not a factor of trauma.
05:56Exposure really seems to
05:58be a factor of active PTSD,
06:00which is where you see the elevated
06:03risk of secondary disorders.
06:05Now I'm going to be focusing a
06:07bit on relationships between PTSD
06:09and substance use because they're
06:11commonly comorbid as we're going
06:13to discuss in just a second and
06:15their associated with a much more
06:17severe course for both disorders.
06:22So if we look at people with PTSD
06:25out of every hundred, about 52,
06:27so a little more than half of an alcohol use
06:30disorder and 35 have a drug use disorder.
06:33When we look at some more recent analysis,
06:37this is from recent epidemiological
06:40data from the new Spark data set that
06:43half of people with lifetime PTSD
06:46also have lifetime alcohol use to
06:49disorder when look among treatment
06:51seekers with substance use disorder,
06:53about 60% have comorbid PTSD.
06:56When we look within past year PTSD.
07:00What we find is about 1/3 of people have some
07:03type of comorbid substance use disorder,
07:06either an alcohol use disorder,
07:08a substance use disorder,
07:10severe drug use disorder, or both.
07:17Now, one of the challenges with this is
07:19that when these two disorders Co occur,
07:22patients struggle much more.
07:24So PTSD and substance use is associated
07:27with an earlier onset of the substance
07:30use disorder and more years of use.
07:32They also associated with more
07:34severe symptoms, fire, suicidality,
07:36more, psychiatric comorbidity,
07:37and worse treatment opens on
07:39that is both in terms of their
07:42reductions in substance use and their
07:44likelihood to drop out of treatment.
07:49So why do these two disorders
07:51tend to go together?
07:52Well, there are several different theories.
07:56The one theory is a high risk model.
07:59Which is that if you are using substances,
08:02it increases your risk of experience,
08:04a traumatic event,
08:05and that in turn influences
08:07your risk of developing PTSD.
08:09And there is data that supports this model.
08:12So for example, if you look at research
08:14around the relationship between
08:16alcohol use and sexual victimization,
08:19be if you look at some data that was
08:22collected at a daily level on days
08:24of why drinking so binge drinking,
08:27what we find is for women,
08:29their risk of being sexually assaulted
08:32on that day increases about 9.
08:34If all this compared to non drinking days
08:36when we look at these of lighter drinking,
08:39what we find is there's a fourfold increase.
08:42So the idea with this models
08:44you might be in situations or
08:46settings where you're more at risk
08:48for experiencing trauma that.
08:50Does it mean that the substance
08:52used caused the trauma,
08:53but it may have left you
08:55slightly more vulnerable.
08:59Now the model that has the most empirical
09:01support and also has been investigated the
09:03most often is the self medication model,
09:06which is that people use alcohol to cope
09:08with PTSD and this one is is a model that
09:11is frequently endorsed in popular culture.
09:14Many people have this belief.
09:15I had a flight that was cancelled
09:18once an everybody in the line,
09:20for example, was saying, you know,
09:22let's go get a drink, right?
09:24That's an example of the
09:25concept of self medication.
09:27This is distressing to me.
09:29And so I will call for alcohol use.
09:31The Despond slept with this model is that
09:34alcohol use is negatively reinforcing.
09:37What that means is so let's say this
09:40person has a memory of a tremendous event,
09:44right for distress goes up.
09:48She then thinks about drinking.
09:50Perhaps she has a drink.
09:54And their anxiety immediately decreases,
09:56so the negative reinforcement
09:58leads to reductions in anxiety.
10:00Now, unfortunately,
10:01what that does is it increases your
10:04likelihood of returning to drinking
10:06in the future with the same queues.
10:12So you can see then there's this
10:15reduction in drinking urges.
10:16Now there's another theory that has
10:19slightly less empirical support.
10:21It's also been looked at less
10:23frequently than self medication,
10:25which is the mutual maintenance model
10:27and the idea with this is that the
10:31two disorders maintain one another.
10:33So with PTSD that leads to both coping
10:36beliefs and also acute cravings, that
10:39increases the likelihood to use substance.
10:41Symptoms of substance use.
10:43Withdrawal can also
10:44resemble symptoms of PTSD.
10:46You could have increased anxiety.
10:48You can have an increased sleep
10:50disturbance and that can increase
10:52PTSD symptoms or can look like PTSD.
10:54You also get avoidance
10:55of trauma related cues.
10:57There is some data supporting this theory,
10:59but somewhat less,
11:00and the relationship seems to be less strong
11:03than what we see with self medication.
11:06Now.
11:06Why are these theories important?
11:08Well,
11:08they may drive approaches for treatment,
11:10and that's what we're going to be
11:13talking about in most of the top.
11:16Now I do want to acknowledge
11:18that it's also possible,
11:20and in fact likely that there are
11:22third variables that increase risk
11:24for both substance use and PTSD,
11:27so that might be helping.
11:28Skills deficits are coping skills,
11:30strategies.
11:31It might be a genetic or other
11:33committed biological vulnerability,
11:34and that might affect risk
11:36for both disorders.
11:40So let's move into talking
11:41about treatment and what do we
11:43know right now about treatment?
11:45So there are several ways that we can
11:48go forward with treating Co occurring
11:50PTSD and substance use disorders.
11:53The one option is to do an integrated
11:56treatment where you treat the substance
11:58used in the PTSD at the same time.
12:01These might be treatments,
12:02life seeking safety,
12:03which I'm going to talk about in just
12:07a second or two months like hope.
12:10Where the therapies are integrated,
12:11there are some advantages to
12:13these types of treatments.
12:14There is some data that patients prefer.
12:16The concept of integrated treatment
12:19where they're getting skills for both.
12:22I think there are a couple of challenges
12:24with these approaches as well,
12:26though often they are longer
12:28than the sole target treatments.
12:30They may be a little bit more
12:32complicated for providers to learn.
12:34They have to learn multiple behaviors.
12:36Farm and drop out his eye.
12:41So and what we find is,
12:43at least in some of the research studies,
12:46the integrated treatments do
12:47not always work better than the
12:49single treatments in PTSD.
12:51So this is a relatively recent paper,
12:54not super recent.
12:55This was looking at seeking safety
12:57as compared to treatment as usual
12:59as compared to relapse prevention,
13:01which is a substance use oriented treatment.
13:04And what we think of is actually
13:06relapse prevention work pretty
13:08well in addressing PTSD,
13:09slightly better than seeking safety.
13:15It did not significantly better.
13:17We also did not find that seeking safety
13:20worked better than relapse prevention.
13:22In addressing the substance
13:24use symptoms in this study.
13:27So it may not be always the best option.
13:32Now another option is to do
13:34two different treatments,
13:35so it used to be that back in the old
13:38days when I was in Graduate School,
13:41we were taught that what you
13:43need to do is have the person go
13:46have their substance use treated,
13:48stabilize them and then treat the PTSD.
13:50So the idea of sequential care,
13:52often therapists are quite concerned
13:54that patients are going to relapse
13:56or going to have difficulty
13:58tolerating a PTSD treatment,
13:59and so that's where some
14:01of this idea comes from.
14:03Now the challenge with this approach.
14:06Is that the data around it?
14:08This is what's often seen in practice.
14:11Is that?
14:14For some patients,
14:15with their saying is look,
14:17it's my PTSD that's triggering
14:19my desire to use,
14:21and so you're asking me to not use,
14:24but you're not giving me coping
14:27skills and so that can be a challenge.
14:30But data on whether substance
14:32use also reduces reduces.
14:34PTSD is a bit mixed at this
14:36point in the literature,
14:38and there is some data that unremitted
14:41PTSD is a predictor of later relapse.
14:44Following substance use treatment.
14:49Yeah, So what we know is that
14:52people with PTSD do appear to
14:54have some out worse outcomes.
14:56Generally in substance use treatment,
14:58although I do want to point out that
15:00substance use treatments defined
15:01fairly broadly in these studies,
15:04so it's not necessarily
15:05always manualized treatments,
15:06but we do see that people with
15:08PTSD and substance use treatment
15:10have higher rates of re admission.
15:13Lower adherence, mayor dropout.
15:14They have shorter periods of
15:17abstinence and higher use of services.
15:19For compassion, for patience as well,
15:21with this approach is that patients
15:23can get bounced around right?
15:24So they try to get treatment for PTSD.
15:27They are told they need to get
15:28the substance use treated first,
15:30but the substance use provider
15:32may not know what to do with the
15:34trauma and that can be a challenge.
15:38Now another option is to do
15:40two different treatments,
15:41so to treat the PTSD and then
15:43perhaps be the substance use.
15:45If it's still an area of concern.
15:50So there is data that treating
15:52the PTSD directly does appear to
15:55reduce substance use symptoms.
15:57And there hasn't been data supporting the
15:59idea that people have yatra genic effects.
16:02Now I do want to put in a caveat
16:04that these studies also still
16:06have high rates of dropout,
16:08which is problem one of the PTSD substance.
16:11Use treatment literature as you're going
16:13to see as I show you some later data.
16:17But what I want to do now
16:20is actually 50 years,
16:21just a little bit and talk about some
16:24research that crazy Simpson and I did.
16:26Basically was the Pi for this study,
16:29and this was actually not designed
16:31to be clinical trial per say.
16:33This was actually an experimental study
16:35to try to understand mechanisms of
16:37change in PTSD alcohol treatments to try
16:40to look at a very condensed treatment,
16:42and whether that could affect
16:44day-to-day symptoms as well as
16:46whether skill use made a difference.
16:48Now the concept.
16:49Find this study is when we talk
16:51about mechanisms of change.
16:53Often we will say here's the treatment
16:55and we may have theories about what's
16:57effective or not effective in the treatment,
17:00and then we do as we study the outcomes.
17:03But we don't tend to study the magic
17:05in the middle to really evaluate
17:08whether that is what is contributing
17:11to making the behavioral change.
17:13For this study,
17:14we recruited 78 people who had comorbid
17:16PTSD and alcohol use disorders.
17:18This was a fairly chronic and severe sample.
17:21Most people had tried other treatments.
17:23We also had a fair amount who tried
17:26residential treatment in the past.
17:28It was a mix of community members
17:31and veterans.
17:3230 two people got cognitive restructuring,
17:3426 data.
17:35Very brief,
17:36experiential acceptance intervention,
17:37and 20 had a nutrition control
17:39who's teaching people about bottom
17:41image portion portion sizes.
17:43For example,
17:44I'm going to mostly focus on the cognitive
17:47restructuring data for this talk now.
17:50The cognitive restructuring intervention.
17:52Actually all of the
17:53interventions were quite brief.
17:55It was a 90 minute scripted intervention fit
17:58off the basic skills of cognitive therapy.
18:02So how do you notice when something happens?
18:05What you tell yourself and how you feel and
18:08then some basic challenging of those beliefs.
18:11People also got for follow up 20
18:14minute booster sessions to just
18:16help them with skill maintenance.
18:18Light, brief.
18:19As an aside,
18:20we consulted a doctor.
18:22Reset was the developer of CPT,
18:24was a consultant on this study and
18:27she had quite a bit of skepticism
18:29that we would see any changes
18:32in behavior with this brief.
18:34In light attached with this kind
18:36of clinical population.
18:41So here is what we found,
18:44so this was a daily diary study so people
18:47used IVR to look at relationship between
18:51drinking PTSD and still use for about 30
18:55plus days following the intervention.
18:57We also collected baseline data which
19:00is controlled for in these analysis to
19:04get a sense of what they're drinking
19:07was like and what their level of PTSD
19:10was like before the intervention.
19:12So what you can see here?
19:15Yes that we had some some various effects.
19:17We've done that alcohol consumption just
19:19in terms of covariates was greater for men,
19:22which we would expect greater for
19:24those who are older and higher on
19:26weekends compared to weekdays.
19:27None of that. Is a particular surprise.
19:30We found that heavier basement drinking
19:32was associated with more drinking on a
19:35given day during the follow up period.
19:37And having completed more coaching calls
19:39was associated with less drinking on a
19:42given day during the follow up period,
19:44we had a main effect for the cognitive
19:47restructuring condition compared to
19:48control and had a significant interaction.
19:50So what we found was for the cognitive
19:53restructuring group they had about
19:55a 2% decrease in drinking per day
19:57as compared to control. That's 2%.
20:00Doesn't sound like very much.
20:02Although again with a very light touch
20:04intervention, it is quite pleasing.
20:06But what this means is that an
20:08individual who consumed 10 drinks
20:10the day after receiving the cognitive
20:12restructuring intervention would have
20:13been down to 5 drinks during the final
20:16day of the follow up period,
20:18and that is a notable decrease in drinking.
20:24What we thought was even more impressive.
20:27An interesting in terms
20:29of informing our thinking.
20:31Was that we could see a clear
20:34relationship between skill
20:36use and changes in drinking,
20:38so we were really interested
20:40in the Association requirement
20:42around mechanisms of change.
20:44What we found was that using more
20:48cognitive restructuring coping
20:49skills was associated with even
20:51greater reductions in drinking
20:53for the cognitive restructuring
20:56condition in particular.
20:58So these are some relationship
21:00between skill use in our controls,
21:02which is not entirely surprising,
21:04but really an Association between
21:06use of skills for those who
21:09are actually taught the skills.
21:11Now this is incredibly important
21:13because it identifies an active
21:15ingredient in treatments for
21:17PTSD and alcohol use disorders.
21:19And demonstrates that you can see
21:21an Association and the use of that
21:24skill and changes in alcohol use.
21:26This has led directly to a body
21:28of research trying to look at a
21:30higher dose of cognitive therapy
21:31for the treatment of PTSD and
21:33alcohol use disorders,
21:34which is what I'm going to focus on.
21:40So for those of you who are not familiar
21:42with cognitive processing therapy,
21:44CPT is an evidence based therapy for PTSD.
21:47It's been evaluated more than 20 randomized
21:50clinical trials and multiple other
21:52types of less rigorous trials as well.
21:54It is a 12 session therapy.
21:57It can be delivered in groups or individually
21:59and it is predominantly cognitive.
22:02It's focused on trauma processing mostly
22:04through the use of Socratic dialogue
22:06or asking really good questions.
22:09And I'm done helping the person evaluate and
22:12shift beliefs about why the trauma happened.
22:15As well as overgeneralized beliefs from the
22:18traumatic event to their present or future.
22:20We were particularly interested in
22:22looking at this therapy because it
22:24does not contain an exposure element.
22:29So the first today I'm going to
22:30talk about is in the talk about
22:33our longstanding collaboration and
22:34research trial with a rural Native
22:37American tribe in Washington state.
22:41So, just to contextualize this research,
22:43study as we move into this,
22:45I want to talk this briefly about
22:48the concept of syndemic theory.
22:50So within the context of historical
22:52trauma from high levels of
22:54poverty and discrimination,
22:55what you can see **** endemics of trauma,
22:59exposure, substance use in HIV risk
23:01behavior so it's endemic is the
23:03aggregation of concurrent or sequential
23:05epidemics or disease clusters,
23:07which exacerbate the prognosis
23:08and burden of disease.
23:10So when we talk about comorbidity research
23:13like the research I've been talking
23:15about with PTSD and substance use,
23:17we tend to focus on the boundaries
23:20and overlap of diagnosis.
23:22Syndemic theory focuses on communities
23:24that are experiencing Co occurring
23:26epidemics that additively increase
23:28negative health consequences.
23:30So for this community,
23:32what we see is PTSD concurrent with
23:35HIV that leads to more rapid HIV
23:38disease progression for survival,
23:40greater costs and services and
23:43lower adherence to medical.
23:45Very few HIV interventions address some
23:48of the risk factors such as trauma,
23:50exposure, mental health and substance use.
23:53An other researchers found that
23:55interventions that failed to do so have
23:58poor rates of condom use in health outcomes.
24:01Outcomes are worse for those with PTSD.
24:04This image is an odds the boarding schools
24:07which did affect this community as well,
24:10were Native American children
24:11were removed from their phones,
24:13isolated from their communities.
24:16And were rates of child abuse
24:18for actually extremely high.
24:22So this particular project was was
24:24a community based participatory
24:26research project address,
24:27comma related symptoms,
24:28and improve the health and well
24:30being of Native American women
24:32whose community initiative initiated
24:34so they approached University
24:35of Washington at the Indigenous
24:37Wellness Research Institute and
24:39asked for help with addressing
24:42trauma within their community.
24:44In partnership,
24:45we went through and talked about
24:47various treatment options and
24:49they felt that CPT would be a
24:51good option for them based on
24:53international work that I had done
24:56with evaluating adapted CPT in
24:58Northern and Southern Rock and in
25:01the Democratic Republic of Congo.
25:03So the idea behind this project
25:05is if we treat the PTSD,
25:07do we see reductions in alcohol
25:09and substance use,
25:10and can we also see reductions
25:11then in high risk sexual behavior?
25:16So for this particular study,
25:18in part because it was the first clinical
25:22trial to evaluate treatments for PTSD.
25:25Within the Native American community,
25:27to think about that for a minute
25:30with this community is the first
25:33novel file in a very high risk.
25:35Collation we had 70 three women from
25:38Pacific Northwest Travel Reservation.
25:40About 71% had a high school degree about
25:43Path had a primary partner baseline
25:45with high rates of palm exposure and
25:48substance use disorders which I'm
25:50going to show you in just a sack.
25:53About 35% of the individuals in
25:55this particular County or below
25:57the poverty line as compared to
25:5914% in the state of Washington.
26:03So in terms of comics Ledger we
26:05had was about three and four had
26:08experienced child sexual abuse,
26:10about three and four reported lifetime
26:12physical assault and two out of every
26:15three met full criteria for PTSD.
26:17We did take subthreshold PTSD
26:20in this particular trial.
26:2270% my criteria for substance abuse or
26:25dependence and 60 four reported binge
26:27drinking in terms of substance abuse.
26:30At 60% my criteria for dependence
26:32and 10% for abused.
26:34Predominantly alcohol with a smaller
26:36subset that were misusing cannabis.
26:42So couple things to point out.
26:44In this we had about a 43% dropout from CPT.
26:48That's fairly comparable with other PTSD
26:51substance use trials and we had about
26:53a 33% dropout for delayed treatment.
26:55We had much greater problems in
26:57this study with loss to follow
27:00up around assessment measures,
27:01even over a very brief follow-up period.
27:04I think in part because that that
27:06piece of it was less compelling.
27:13So the dig into some of the results.
27:15So this is the data on CPT
27:18as compared to the wait list.
27:20What we found out was that among the
27:22participants in the immediate intervention
27:23condition as compared to participants
27:25in the wait list control condition,
27:27we had an 8 point greater post baseline
27:30reduction in PTSD symptoms severity.
27:32This is miss somewhat lower drop in
27:34PTSD and then we see another CPT trials.
27:37I think reflecting the level of
27:38severity of distress in the population,
27:41we also found a dose effect where.
27:43Each additional CPT session
27:46attended was associated with 1.3.
27:50Greater reduction in PTSD symptoms and
27:52just to clarify everyone in the wait list.
27:54Then received the PT.
27:56We didn't leave people dressed in white.
28:00In terms of our hypotheses around
28:02substance use, what we saw was a
28:05significant decrease in alcohol use for
28:07the people received, CPT announced.
28:08There was a 1.4 greater reduction
28:10in the frequency of alcohol use
28:12and a .8 point greater reduction in
28:15the frequency of illicit drug use.
28:17A smaller effect.
28:18But we also have fewer people
28:20using illicit drugs.
28:21We felt we had no significant
28:24differences in alcohol problems,
28:25total sexual risk behaviors and
28:28rates of non condom protected sex
28:31and we saw fewer effects than
28:33we would have liked on HIV risk.
28:35We did see again a dose effect for
28:38each additional CPT session attended
28:41was associated with a .4 greater
28:43reduction in alcohol problems.
28:45Now just to follow up on this where we
28:48are now with this body of research,
28:51we found that on average the women
28:54attended about 6 missions and so based
28:56on this right now what we're looking
28:59at is the use of narrative exposure therapy,
29:02which does not involve
29:04practice between sessions.
29:05It has no writing component.
29:07It's been used extensively with refugees
29:09and was developed predominantly for
29:11use in low and middle income countries,
29:13and we're comparing that to motivational
29:16interviewing versus skills training.
29:17To try to dig in a little bit more about how,
29:21how can we help get some at HIV risk
29:23behaviors down as well with this community?
29:26And that trial is,
29:27I think about five artist.
29:28Spence,
29:29short of being completed,
29:30so I have answers for you about
29:32how that worked in a little bit.
29:36So I'm going to shift gears just yet
29:39again and talk about another child where
29:42we really did try to dig in on this
29:46question of which roots might help the
29:48most based on the body of literature
29:51around treatment of PTSD and substance.
29:53Use the based on this prior body of work.
29:57It's worth evaluating.
29:58At least we felt it was the
30:00alternative approach of predominantly
30:02targeting one or the other disorder.
30:05The field of PTSD,
30:07substance use, comorbidity,
30:08move very quickly to integrated treatments.
30:10Without many studies focused on
30:12PTSD treatments as a potential
30:15pathway to recovery,
30:16So what we were interested in is
30:19if you use a high quality PTSD
30:22therapy as compared to high quality
30:25alcohol use disorder therapy.
30:27What happens with both the primary
30:30target disorder and the secondary
30:33disorder during the course of treatment?
30:36And our idea with this is that
30:38this may help improve treatment.
30:41An informed standard practice.
30:42So we recruited from the VA and
30:44Community and randomize people to CPT,
30:46relapse prevention or daily assessments.
30:48Let me show you that.
30:53So individuals randomized now
30:54for this particular study,
30:55and there are some results that
30:57I'm not going to delve into
31:00just in the interests of time.
31:02During this phase of the trial here.
31:05People were conducting IVR assessments
31:08daily both through two week baseline and
31:11then over the 12 weeks of treatment.
31:15Six weeks for assessment only.
31:18So that we could actually study
31:20over the course of therapy.
31:22Some of those questions that we looked
31:24at in that smaller trial of are we
31:26seeing skills use make a difference and
31:28how can we understand the process of
31:31change during the course of therapy?
31:33I'm not going to go into those results today,
31:36but I do want you to be aware
31:39of that part of this study.
31:42So in terms of this child,
31:43what I'm going to be talking
31:45about is this initial comparison,
31:47and then also the results for the long term.
31:49Follow up for the group that
31:52were collapsed in.
31:53Randomized so with this particular project,
31:57randomization was stratified by gender.
31:59PTSD severity and alcohol use severity.
32:02People had to meet full criteria for PTSD.
32:06On an for an alcohol use disorder.
32:09And they needed to be willing to
32:11think about changing their drinking.
32:13The exclusion criteria were uncontrolled,
32:15psychotic manic symptoms,
32:17recent suicide outer homicide,
32:18ality if they were currently
32:20in a violent relationship,
32:22or if they were experiencing
32:24withdrawal symptoms,
32:25and if their medications have been changed.
32:28If they had taken an abuse in the past month,
32:32or if they were already in an evidence
32:35based PTSD or alcohol use treatment.
32:40With this therapy for this trial.
32:43What we did is we ask that each treatment
32:46be delivered in a non adapted way.
32:49So what that means for CPT is
32:51the drinking was addressed.
32:53It was addressed when it functioned
32:55as avoidance and it was addressed.
32:57If there were particular cognitive
32:59distortions about drinking that were
33:01getting in the way of recovery from
33:04PTSD and participants were encouraged
33:06to use the CPT skills to work on alcohol
33:08related thoughts when they came up.
33:11But it wasn't a major focus
33:13in the therapy sessions,
33:14except in these cases.
33:16In relapse prevention,
33:18PTSD was addressed as a trigger
33:20for craving or drinking.
33:22And was addressed when excuse me,
33:24but in explicit discussion of trauma,
33:27memories was prohibited.
33:32So in terms of what we controlled for and
33:35just the demographics about the sample,
33:38the sample on average was about 42.
33:43101 participants most of
33:45our participants were white,
33:47followed by African Americans.
33:50Individuals who were multiracial in
33:53a smaller subset were Asian Native
33:56American and about 21% were Hispanic or.
34:01Most the single and never married
34:0433% were college graduates and 38%
34:06were working full or part time,
34:08so it's a fairly impoverished sample.
34:12I did find that associate different
34:14demographic variables were nonsignificant,
34:16but a higher proportion of individuals
34:19in the relapse prevention condition
34:21were employed about 58% and had
34:24annual household incomes above 40%.
34:27All of our models that I'm going to be
34:30discussing controlled for differences
34:32in PTSD and drinking outcome.
34:35Or excuse me.
34:36All of the models controlled for
34:38sociodemographic variables of sex,
34:40age, race, and ethnicity,
34:41employment status, and treatment site.
34:45Treatment was conducted at a community
34:48trauma clinics as well as the Seattle VA.
34:52So let's look at how each active condition
34:55did as compared to daily monitoring.
34:57With weekly Checkins or
34:59the control condition.
35:00Now these are intent to treat analysis.
35:02The first set that I'm going to show you,
35:06it looks at the effects of CPT and relapse
35:09prevention as compared to assessment only.
35:11These are mixed effects models
35:13that include fixed effects for
35:14covariate condition and condition
35:16by time interaction terms.
35:20So what we saw in this initial this
35:22is just baseline to post treatment.
35:25Was that there was a significant
35:28improvement overtime across all conditions.
35:32We also did find an interaction
35:34with time by condition effects
35:36that were significant for CPT
35:38versus assessment only in the model
35:40predicting PTSD symptoms severity.
35:42Now it wasn't significant,
35:44but relapse prevention also was associated
35:46with decreases in PTSD symptoms
35:48severity as compared to assessment only.
35:50But as I say, it didn't actually
35:53hit the mark for statistics.
35:59We did find that both active treatment
36:02and dish conditions were associated
36:04with reductions in drinking and
36:06as compared with assessment only.
36:08But this interaction boots.
36:10Did not reach statistical significance.
36:15In terms of reductions
36:17in heavy drinking days,
36:19what we found was a statistically
36:22significant difference from baseline
36:24to post treatment for both their
36:26face as compared to assessment only.
36:29What we found was that those in CPT had
36:33about a 50% greater decrease in heavy
36:36drinking days as compared to assessment only.
36:39Relapse prevention participants had a 66%
36:41greater difference or greater decrease.
36:46So let's talk about change overtime.
36:48One of our primary questions was
36:51would these changes be maintained?
36:54And so for this second set of
36:56analysis with this includes the
36:58people who were re randomized,
37:00what initially got an assessment
37:02only were re randomized after
37:05their initial follow up.
37:06And so for those originally in
37:08the assessment on my condition,
37:10the first follow-up was treated
37:12as their pretreatment timepoint.
37:16The treatment and assessment completion
37:18rates were definitely not optimal,
37:21so about 52% as compared to 58% of CPT
37:26versus relapse spread to people attended
37:2975% or more of treatment sessions.
37:34On what you can see is really
37:36a substantive decrease,
37:37and people are making it to that one year.
37:41Follow up. Wait for that final follow up,
37:43but this is unfortunately pretty
37:45consistent with what we see in the
37:48PTSD stuff into the literature.
37:50Which is, it's really hard
37:51to hang on to these folks.
37:54Treatment completion rates.
37:55Actually, I think it's interesting
37:58that they are quite similar for
38:00CPT versus relapse prevention.
38:02And again,
38:03I think it argues that people can
38:05tolerate trauma focused therapies,
38:07or at least in anymore ************.
38:09Then another effective treatment.
38:15So what we found is that both
38:18treatments were associated with
38:20reductions in PTSD overtime.
38:22These were substantial reductions
38:24in PTSD symptoms severity,
38:26prevalence of meeting criteria
38:28for PTSD remission ranged from
38:30about 23 to 41% across the follow
38:33up time to meet some conditions.
38:37We also found that both treatments
38:39were associated reductions
38:40in days of drinking overtime.
38:45And that both treatments were
38:47associated with substantial reductions
38:49in days of heavy drinking overtime.
38:52We did see that those in relapse
38:55prevention showed statistically
38:56significant greater reductions in
38:58heavy days of drinking from pre to post
39:01treatment as compared to those in CPT.
39:04So it's about a 45% greater reduction
39:06in heavy drinking days and the ranges
39:09of those meeting criteria for low risk
39:13drinking range from about 42 to 52%.
39:18Now, with this particular study,
39:20what I would say in terms of take,
39:22some take home messages is that both
39:25treatments had significant significant
39:27effects on both primary and secondary tar.
39:29So more people assigned to CPT than
39:32relapse prevention experienced
39:33in early remission from PTSD,
39:35which may be helpful for some
39:37patients in reducing relapse risk.
39:39Don't treatments were associated with
39:41reductions in drinking relative to
39:43assessment, only at post treatment,
39:46and those early reductions in
39:48drinking or the sustained overtime.
39:51As you noted,
39:52I'm sure that there were challenges
39:53both with recruitment and drop out.
39:55We were able to recruit about
39:57half of the sample that we had
39:59hoped to get for this trial,
40:01so we were underpowered
40:03to detect differences.
40:04We had stricter entry criteria than
40:06many such studies which may have
40:07affected our ability to recruit people.
40:09Had to have an active alcohol use disorder.
40:11They had to have recent drinking and
40:13they had to have full criteria for PTSD.
40:16We should not take some threshold
40:18for this study.
40:19Then people had to be willing to treat
40:22either disorder or wait for care.
40:24We also found that some people had
40:26already reduced their drinking by baseline.
40:27They were primed and ready to
40:29make those changes,
40:30and those were folks that we
40:32had to take from the trial.
40:34And some people anecdotally needed seem
40:36to need one treatment or the other.
40:38It was very interesting in
40:41our consultation calls.
40:43Their therapist would sometimes
40:44say I wish this person have gotten
40:46randomized to the other condition,
40:48and I do think that that begs
40:50the question for future research.
40:52To really look that treatment matching.
40:55Ann about anecdotally,
40:55about a third of those assigned
40:57to relapse prevention,
40:58or disappointed because they wanted
41:01to work on the trunick of that.
41:04The bigger picture take home
41:06messages on PTSD and substance use.
41:07Go hand in hand so we gotta figure
41:10out how best to treat this.
41:12And there is a high burden of disease
41:15associated with these disorders.
41:16Patients often do have a preference
41:19for one treatment versus another.
41:22And cognitive trauma focused therapies
41:24may have some promise for addressing
41:26PTSD and substance use disorders,
41:29so they're worth pursuing as an
41:31additional option for treatment to
41:34increase our our range of interventions
41:36over and above some of the non trauma
41:39focused therapies and some of the
41:41more exposure focused therapies and
41:43overall drop that is a problem in this field.
41:47So we've gotta find some interventions
41:50that are a little more sticky.
41:53Or some strategies to help people stay in,
41:56especially given some of the findings
41:58that we had about dose effects.
42:00I would say overall,
42:01there's increasing evidence that
42:03there is no wrong door for treatment.
42:06An providers might be able to have
42:08good treatment outcomes on both
42:10disorders using high quality,
42:12evidence based interventions targeting
42:14either PTSD or substance use, or both.
42:18And with that.
42:20Any questions?
42:27Thank you, Deborah.
42:29Very, very interesting and
42:31important conclusions where you
42:34you for your talk and so want to
42:37open this up for questions to you.
42:40Maybe I can begin with
42:43with just the observation.
42:45So it suggests that you that that
42:48individuals be given a choice of evidence
42:52based treatments when they enter.
42:54When they have Co occurring PTSD in
42:58a substance use disorder and then.
43:01Clinicians,
43:01are you recommending Christians
43:03follow that choice as as long as
43:06the treatment is evidence based?
43:09I mean, I think that's an empirical question.
43:12Right, but I think it's one that we need
43:14to ask Lori Zoellner and Orfini have
43:17done some really wonderful research
43:19looking at the impact of choice on
43:21when we give people with PTSD a choice
43:23between medication versus psychotherapy.
43:25How many choose medication?
43:26How many choose psychotherapy and
43:28then what's the implication if people
43:30don't get what they what they chose?
43:32That kind of research has not happened to
43:34date as far as I know in the PTSD substance.
43:37Do you feel that patients often
43:38have an idea or have a preference,
43:40and I think that is the next natural step
43:42in the field is what would you pick?
43:45What do you want to do?
43:46And then does that make a difference
43:48in how likely you are to stick with it?
43:51Right and I can see arguments either way.
43:53It may be that the PTSD avoidance
43:55is compelling and people say, oh,
43:57I don't want to talk about that
43:59and maybe those the people actually
44:01need a trauma focused therapy.
44:03Or it may be that people actually
44:05have a good idea about what they're
44:07able to do or what pathway to recovery
44:10may be most approachable for them.
44:13Identification.
44:15Hi
44:15my name is Sophia and I'm a fourth
44:18year psychiatry resident who's really
44:19really interested in trauma and PTSD.
44:22And I also listen to hear
44:24this merican life quadcast,
44:25the one with twelve sessions on CPT,
44:27which was really,
44:28really insightful. Honestly,
44:29to hear from a patient's perspective,
44:31just going along with choice.
44:32I also just wanted to ask you about like
44:35group CPT versus 1 to one CPT as well,
44:38because you know in groups
44:39there's a group stare right?
44:41And a lot of group modalities for this,
44:43and I guess I'm in my research I I guess I
44:47don't have a great sense of like does group.
44:51If someone also prefers group like,
44:53is it as helpful as one to one?
44:56I've also heard that you know a
44:58lot of trouble like healing from
44:59trauma happens in groups too.
45:01When you feel really seen and heard
45:02and validated by other people.
45:04So I just want to ask your opinion on that.
45:07Yeah, I love it and I'm happy to
45:09take questions about anything I I am
45:12absolutely fearful to talk about any
45:14kinds of topics that you're curious about
45:17in terms of group versus individual.
45:19I have an empirical answer and
45:21then I have a broader answer,
45:23so there just was a trial.
45:25I think they just presented the outcome
45:28data relatively recently at IST SS,
45:30where they looked at individual
45:32versus group CBT.
45:33It's actually the first trial that's
45:35done that head to head comparison.
45:37To answer exactly the kind of questions
45:39Sofia that you're bringing on.
45:41And what they found was that individual
45:44was slightly more effective.
45:46And I think there are some reasons for that.
45:50With individual therapy,
45:51you're getting more airtime for
45:53working on your specific stuck points,
45:55and the therapist can help guide you.
45:58If you're getting a little bit
46:00more avoidant directly,
46:02easier to get missed in a group setting.
46:05Now.
46:05That being said,
46:06I think for some clients group is an
46:09incredibly powerful way of recovering.
46:14Asians? Sometimes listen to each other
46:16much more deeply than they listen to us.
46:19People have had the same to
46:21live the experiences of them,
46:23and it's also great for them to
46:25get to be in the healer mode.
46:28In Congo, CPT was delivered
46:30entirely by group and it was
46:33wonderful hearing our group members
46:36have to meet other staff points.
46:41And that's a way of learning and
46:43we learn through teaching, right?
46:44And so that's also a very
46:46powerful kind of learning.
46:47The other thing that's great about great,
46:49this is cost effective.
46:51Right, so you know if
46:53you have two therapists,
46:54an 8 people in a group as a whole
46:56lot more people in two hours
46:58than you would do with everybody
47:01seeing them individually.
47:05Thank you. Muscle. I
47:08wonder Doctor case and if the
47:10combination of both wouldn't
47:12be really effective, you know?
47:14I mean, for the person who
47:16wants the mutual support,
47:17maybe you start with group and
47:20you don't get into the intensive.
47:22Trauma is much,
47:24but you gain the coping skills.
47:26You know that can help you
47:29address it in a deeper way,
47:31or vice versa for someone who
47:33doesn't want to expose themselves
47:34to a group experience because
47:36of their shame and other issues
47:38around the trauma you know.
47:40And they do that.
47:41And then with some confidence can
47:43go into the group and gain that
47:45mutual support that will really
47:47reinforce 'cause as we know, PTSD.
47:49And you know the trauma.
47:51It takes a long time to heal.
47:53It's not going to be just one session of IOP,
47:55or you know.
47:57You know that's going to help them,
47:59and that's going to be a done deal.
48:01Damn you are so wise and I absolutely
48:04agree with what you're saying.
48:06And there is some great work
48:08that's being done.
48:09For example,
48:09it's rubbish.
48:10They have a two week that that like
48:13so when people talk about like
48:15what's an advance in the field,
48:17you're super excited about this program.
48:19I am over the moon with.
48:21I think it's so cool and Pam it
48:23comes in with some of the types of
48:25ideas that you're talking about.
48:27It's mask treatment,
48:28so it's intensive outpatient program.
48:30It's it is not for comorbid, it is for PTSD.
48:35People can have comorbidities,
48:36but it's not focused on PTSD alcohol use,
48:39but people get daily CPT for two weeks.
48:43And they get both group an individual.
48:47And the results they're getting.
48:49It's for active duty military or veterans.
48:52The results they're getting in an
48:55active duty and veteran population
48:57look like civilian samples.
48:59Typically we get smaller effect sizes,
49:02smaller benefits from treatment
49:05when we have military members.
49:08And So what they're getting with
49:10doing that kind of intensive
49:12treatment is very low dropout,
49:14less than 10%,
49:16and huge treatment gains in two weeks.
49:20I think that's just fabulous,
49:21but I also think that that combination
49:23of individual and group helps.
49:24I see that Deborah has a hand up number.
49:27You are much more polite than me.
49:29I'm a jumping in person,
49:30but I want to reinforce lovely day of yours.
49:34Oh, you're muted though.
49:38Forgive me if you addressed this,
49:40but how do you rate EMDR with
49:42CPT in the other interventions?
49:44'cause I know in this community
49:46I often I'm working with someone
49:48who's had trauma and I'm a dynamic,
49:51is psychiatrist, and I do can calm and
49:54send them to someone who does EMDR.
49:57But I don't know the outcome
49:59literature and comparatively with CPT,
50:01so that'd
50:02be great. Thanks.
50:03Yeah, I'm happy to talk to that.
50:06There are no EMDR to CPT
50:08head to head comparisons,
50:09so I can't directly speak to,
50:12you know, if there was a horse race,
50:15I would they do what I can say is ISTSS just
50:19did a comprehensive analysis of the data.
50:22It was beautifully done, project all
50:24of the questions were preregistered.
50:27We had people from all of the different
50:30therapies represented as people approached.
50:32Looking at the literature and the
50:34three therapies that got our sort of
50:36strongest recommendation in terms of
50:38the strength of the literature work,
50:40a long exposure.
50:42CPT and EMDR,
50:43and so it is a I don't do
50:45EMDR not trained in it,
50:48but it is a therapy that I feel very
50:51comfortable referring people to because
50:53it is an effective therapy as well.
50:59Did that answer your question, Deborah?
51:02Yes, now if we're going back to the
51:04issue about comorbidity though,
51:06I don't know of any child's that
51:08have looked at EMDR for PTSD,
51:11substance use comorbidity,
51:12so I think that's an open question.
51:14We know PE works right,
51:16and we know that cope,
51:18which is PE overlaid with
51:20substance use treatment works.
51:22And we know that CPT works,
51:23but I don't know about EMDR because
51:25the studies haven't been done.
51:29Doctor Kayson yeah can I ask you another
51:32question about like Centers of excellence? I
51:34am all yours, I'm all yours.
51:36Thank you. Appreciate it.
51:39So you know I've been trying to find
51:42like centers of excellence for PTSD care
51:44that they are outside of the VA and
51:46like it for civilians instead of vets.
51:48'cause you mentioned it like an
51:50example of our really awesome,
51:51more intensive like IOP sort of program
51:54for that are that is still for vets
51:56like I know about like you know the
51:58Trauma Recovery Center at UCSF but
52:00like are there that many programs out
52:02there that provide different types of
52:04like choice in PTSD care and multiple
52:06types of treatments for civilians.
52:08Yeah, so so here this is actually
52:11in many ways mild life mission,
52:14which is that we've done an outstanding
52:17job disseminating therapies for
52:19PTSD for our service members.
52:21And there are so many people have
52:24experienced these types of events.
52:27Who are not service members and for them
52:30getting good care is really murdered.
52:34What I can tell you is,
52:35so there are definitely some places
52:37Emory's got a wonderful clinic.
52:38Um, so I would put Emory on that list.
52:42You're exactly right.
52:43UCSF does a beautiful job and then
52:46you can find individual places,
52:48but it's there isn't like a network.
52:50So for example, and I know a lot
52:53of Washington state resources,
52:55'cause that's where I was for 17 years case.
52:59ARC is the King County sexual assault,
53:01something something?
53:02There are wonderful program.
53:04They provide either sliding fee or free QR
53:07for sexual assault survivors in King County.
53:10Whole age range from 6 to whatever
53:12and they provide various treatments.
53:14The Harborview Center for Sexual
53:16Assault and Traumatic Stress,
53:17so you'll find these places.
53:19Stanford now has started up
53:21a PTSD clinic where we have a
53:23whole variety of interventions,
53:25but the problem is,
53:26is that enough time?
53:27There isn't a great network.
53:30Around centers of excellence
53:31as you're talking about,
53:32so I hope you maybe pick that
53:34up as your mission in life.
53:37Thanks, Patrick. Listen I'm
53:38going to send you an email if you
53:40don't mind about this. 'cause
53:41I got really obsessed but I don't mind
53:43at all and and you can feel free to
53:44nag me 'cause periodically my inbox
53:46becomes something that is aversive.
53:48And so if I don't respond right away.
53:51Von, it looks like you've got
53:53a question. I think that's great talk.
53:56I think understanding the
53:58overlap with comorbidities,
53:59especially in substance use
54:00disorders not well understood.
54:02So it's really good to see the overlap
54:05and trying to tease them apart,
54:07and that more treatment in
54:09general is effective.
54:10I'm I'm curious if you have
54:12thoughts on on two topics.
54:14One, what brain functions do you think
54:17are changing with your interventions
54:19and are they similar and different
54:21that are driving PTSD and Sud?
54:24Improvement and then with the
54:25comorbidities of PTSD and STD and the
54:28use of transcranial magnetic stimulation
54:30to treat either of those diseases.
54:32What are your thoughts on maybe
54:34adding TMS as an add event to
54:36your ongoing interview base or
54:38or group based interventions?
54:40And you think that might so
54:42for your first question,
54:44what
54:44I will say is I am far more
54:46of a public health community.
54:49Health services kind of researcher,
54:51so I leave the neurobiology to
54:54people who are smarter than me.
54:56So I have no idea I'd have to go
54:58and delve and really think about
55:00what we think are mechanisms.
55:02I'm a mentor right now on a K,
55:04where I'm hoping that that person
55:06will be the person to help me figure
55:08that out during these treatments.
55:09Brilliant scientist is a mechanical engineer
55:11who is now interested in our science.
55:13I hope the grant funds.
55:15Um, in terms of the transcranial
55:17magnetic stimulation,
55:18that is a really exciting direction.
55:20I think in the field there is a study
55:22that is going on right now that's looking
55:25at that combined with CPT just for PTSD,
55:28so we'll find out soon whether we
55:30get additive effects with that.
55:32So I can say that you're thinking
55:34right in the same lines as some
55:37of the other people in this field
55:39when we add in the substance use,
55:42I think that's a really interesting question,
55:44especially with.
55:45High rates of drop out of can we
55:47get people better a little faster?
55:49Maybe that'll make it easier for people
55:51to stick with the therapies as well.
55:53Good question thanks.
55:54I look
55:54forward to seeing the
55:56results of that. Yeah, yeah,
55:57keep an eye out.
56:00Labria I gotta question in the chat.
56:04That was sent to me.
56:06Person was intrigued by the use
56:07of CPR in the development of the
56:09trial for American Indian for
56:11the American Indian community.
56:13You described.
56:14What do you think would was the
56:16impact of allowing the community
56:18to choose the intervention?
56:19And how do you think CPR can
56:21continue to inform work with
56:23this population and with others?
56:26Yeah, absolutely.
56:26It's a wonderful question,
56:28so let me talk a little bit about that
56:30relationship with this particular tribe,
56:32'cause they think it's really
56:34important to talk about. So.
56:36The tribe had actually approached
56:39University of Washington long
56:41before this trial was begun.
56:44An I think it's important that this
56:46trial was not investigator initiated.
56:48It wasn't us with our idea
56:50about how to help people.
56:52Coming to a community,
56:54but it was actually the community asked,
56:57asking to partner with us and then us
57:00together coming up with a solution.
57:02But that man is we actually had
57:05quite a bit of Community client.
57:09And they felt like they had a
57:11voice in the whole process.
57:12This the data belongs to the tribe.
57:15The data for this project isn't ours.
57:17It's not the investigators.
57:20That helped quite a bit with recruitment,
57:22but it also helped with
57:24the adaptation process,
57:25so we had tribal elders.
57:26We had Native American clinicians
57:28who all helped with the development
57:30of the adapted materials.
57:31An example I wish I had a slide to show you.
57:35So for those of you who are familiar
57:37with the worksheets in CBT or other
57:40cognitive behavioral therapy is right.
57:42So we've got this worksheet that's got
57:44these columns on it an A lot of text,
57:47right?
57:49When the community reworked the worksheet
57:52an away where it was overlaid over
57:55a picture of a mountain and rather
57:58than a left to right processing,
58:00it actually was going from bottom
58:02to top 'cause you're climbing the
58:05mountain to get to the adapted thought.
58:08I hate that worksheet it makes my brain
58:11hurts however it was so fascinating
58:13presenting that worksheet to our therapist,
58:16some of whom were Native American
58:18and some of whom were not.
58:21And our clinicians,
58:23who are Native American more like.
58:26Yeah, that finally makes sense for me.
58:29And so I do think we can get things that
58:33resonate better for a community when
58:35we listen because we are academics.
58:38We know lots of things,
58:40but we don't know all the things.
58:44And so that part is important.
58:47If we have time,
58:48I can talk to you about a project
58:50that Lori's owners doing,
58:52partnering with a samale community,
58:54which I think is one of the most
58:56elegant examples of a culturally
58:58adapted PTSD therapy I've ever seen,
59:00and it really came out of that
59:02CPR concept and listening to the
59:04Community and then bringing our
59:06knowledge to the table.
59:08But welding it with what the community knows.
59:13Thank you Deborah.
59:14I just wanna follow up.
59:16There was another question
59:18that was sent to me separately
59:20which was give a sense of the
59:23differential influence of CBT
59:25CPT on PTSD symptom clusters
59:27and ultimately substance use.
59:30That's a fantastic question.
59:31We have not analyzed that data yet,
59:34but we definitely will.
59:35I am also very curious of where is
59:39it that we're seeing the changes?
59:41Is it? Is it that we're pushing
59:44down on avoidance, right?
59:45That's a possibility.
59:46Is it that we're shifting hyperarousal?
59:49Are there particular clusters that are more
59:52predictive of changes in substance use on?
59:54There are studies that are more launch
59:57tunele studies looking at which PTSD
60:00symptom clusters seem to be most associated.
01:00:02With substance use,
01:00:03but the data is all over the place.
01:00:06Some studies find that it's
01:00:08driven by true symptoms.
01:00:09Some studies sign that
01:00:10is driven by avoidance.
01:00:12The findings are super inconclusive,
01:00:13and so I think looking at a cognitive
01:00:16intervention and what do we see
01:00:18changes and predicts change in
01:00:19substance use would be fascinating,
01:00:21and we have that data daily level.
01:00:24Right,
01:00:25so we'll actually be able to look at it.
01:00:28Overtime over the course of therapy.
01:00:31Deborah,
01:00:31this is Tami sold and that was
01:00:34actually my question and I'm curious
01:00:36to know what your thoughts are about
01:00:38symptom clusters in the relationships
01:00:40of from PTSD to substance use
01:00:42being different by population,
01:00:43and I referenced traumatic events so
01:00:45those who have experienced sexual
01:00:47assault versus partner violence.
01:00:49And of course people who experience
01:00:51one type of trauma tend to
01:00:53experience many types of trauma,
01:00:55but I wonder if you have
01:00:57any thoughts about that.
01:00:59Yeah, well, we didn't see that.
01:01:02You know,
01:01:03I know the daily data pretty well
01:01:05because one of my studies was any.
01:01:07I'm a study with college women had
01:01:09experienced sexual assault and it
01:01:11was one of the first studies that
01:01:13actually tried to breakdown at a daily level.
01:01:15What do we see with specific
01:01:17symptoms of PTSD?
01:01:18So we did a factor analysis and then
01:01:21we looked at what predicted drinking.
01:01:23And you know what we found was
01:01:26not entirely what we expected.
01:01:28Tammy was.
01:01:28So what we found was that there were
01:01:31very specific symptoms of PTSD.
01:01:33There were,
01:01:34so she would hide higher drinking
01:01:36in that population.
01:01:37So we found that it was more the
01:01:40like Hyperarousal and a little bit of
01:01:43the intrusive symptoms that predicted it.
01:01:45But we found that other symptoms of PTSD
01:01:48were associated with lower drinking,
01:01:50so the more dysphoric symptoms of PTSD.
01:01:53Predicted lower drinking on a given day.
01:01:56What was also interesting in that
01:01:58study that I think the field
01:02:00hasn't played with enough,
01:02:02is that we didn't find it at a
01:02:05between persons level of analysis.
01:02:07We found it on a within person's
01:02:10level of analysis.
01:02:11So what I mean by that is it wasn't
01:02:13so important whether my hyperarousal
01:02:16intrusive symptoms were higher than yours.
01:02:19It was if my intrusive symptoms
01:02:21are higher for me than my average.
01:02:24I am more likely to drink on that day.
01:02:28Write an I am likely to drink more.
01:02:31For last, if it was a dysphoric symptom,
01:02:35and so I do think that question
01:02:37of the person's
01:02:38own individual mean their own individual
01:02:42baseline is an interesting one.
01:02:44Now when we look across populations,
01:02:47you know so much of this work
01:02:50has been done in veterans.
01:02:53But I do think that we likely have
01:02:56slightly different presentations
01:02:57and a veteran sample, for example,
01:03:01than sexual assaults in full.
01:03:04In terms of both,
01:03:05what PTSD symptoms may be most
01:03:07prevalent and which ones may be
01:03:10more associated with drinking?
01:03:11If I can rip off of that
01:03:14actually as well family,
01:03:15the other thing that the field
01:03:18doesn't talk about very much is where
01:03:21is the person in terms of force.
01:03:23How long have these
01:03:26behaviors been associated?
01:03:27Right, so the college women have
01:03:31had those associations in theory
01:03:33for a shorter period of time.
01:03:36In that that data that I presented
01:03:39the R 21 that Tracy and I worked on.
01:03:43You know we looked at different
01:03:45motives for drinking and that was one.
01:03:48For example,
01:03:49we saw real relationships for
01:03:51enhancement motives, right?
01:03:52I drink because I'm trying to
01:03:55feel something which we don't
01:03:57talk about very much.
01:03:58We talk about coping motives.
01:04:01And I think that's something
01:04:04we're going to be more likely
01:04:07to see in a Masonic stamp.
01:04:10With the college women we saw lots
01:04:13of celebratory social drinking.
01:04:14As well as coping drinking.
01:04:16So for them we saw both and
01:04:18we've seen that pattern as well
01:04:19to longitudinal study of young
01:04:21lesbian and BI women where we
01:04:23see that pattern sometimes.
01:04:24I'm just drinking to have fun with
01:04:26friends and then sometimes I'm
01:04:28drinking to manage my symptoms.
01:04:30That was a really long answer.
01:04:32I'm
01:04:32sorry Tammy. No no,
01:04:34that was a great answer. And
01:04:36Interestingly, we actually just looked
01:04:38at the Association of PTSD and smoking
01:04:40among women who are experiencing
01:04:42partner violence and found the same.
01:04:44It was stimulation and state
01:04:45enhancement is associated with smoking.
01:04:47No, that wasn't. If you do,
01:04:49you want me to send you that paper
01:04:51where Tracy and I looked at the
01:04:54enhancement motives and drinking?
01:04:59Sounds like she said
01:05:00yes sorry. Sure yes, yes, yes they do.
01:05:03You have to say yes, you
01:05:05won't hurt my feelings.
01:05:06I'm always pleasantly
01:05:07surprised when someone read
01:05:08something I wrote. I was on
01:05:10mute. Yes, Please remember.
01:05:12There's a ton of go ahead.
01:05:14There's a general question in the
01:05:16chat that I wanted to ask you,
01:05:18someone, someone asked,
01:05:19did you look at patients with
01:05:21service connection pending?
01:05:22And whether that was correlated
01:05:24to drop out or outcome?
01:05:27Yeah, no, that's an incredible question.
01:05:29So because the study was not
01:05:32at VA per Southeast study,
01:05:34we did not collect data in this
01:05:36study on service connection.
01:05:38So we ask people if they
01:05:40were of actions or not,
01:05:42but it wasn't sort of an official VA study.
01:05:46So the way the veteran piece went is
01:05:50patients could choose if they wanted
01:05:52to be seen at the VA or at the clinic.
01:05:56That was up to them.
01:05:58If somebody identified as a veteran,
01:06:00they automatically went to the
01:06:02VA to get their their sessions,
01:06:04but everyone else could just kind of
01:06:06pick what was more convenient for them.
01:06:09Um, and so the focus of this was,
01:06:11I think, less veteran oriented than
01:06:14if it had been more of a VA study,
01:06:17so I don't have that data for you.
01:06:19It's a great question.
01:06:26Other questions for Deborah.
01:06:33Doctor case and I just wanted to
01:06:34know is it and I don't even know
01:06:37if this is inappropriate to ask,
01:06:38but is it possible for
01:06:40us to have a copy of your
01:06:43of your presentation?
01:06:44I just want notes fast enough an
01:06:46you know, so that's my thing.
01:06:50Yeah no, no worries Pam, no worries.
01:06:52Usually we have the talk has been
01:06:55recorded and so it'll be available.
01:06:57Trisha and should be the following
01:06:59week, right? Is that the
01:07:01case? Yes, it should be available
01:07:03early next week on the Department
01:07:05of Psychiatry Grand Rounds website.
01:07:09Great project. No problem.
01:07:14Other questions or comments?
01:07:17Mary
01:07:19environment. I was quite taken
01:07:23by the story of the mountain and
01:07:26going from the bottom to the top,
01:07:29that East communication with
01:07:31the native Indians and it kind
01:07:34of brought into my memory at.
01:07:38An moment when I was considering
01:07:42to go to work in Africa with
01:07:44dramatized situation estimate,
01:07:46traumatized population,
01:07:47and at that time I had a friend who was.
01:07:52She's a black lady and
01:07:55she was here Adele studying
01:07:58African American arts.
01:08:00And I was talking to her about art therapy.
01:08:05I'm quite naive in it and her
01:08:09immediate reaction was up struct
01:08:11art. And kind of surprised, maybe because.
01:08:17Yeah, it just didn't expect it.
01:08:19You know that her immediate very
01:08:21quick reaction was that this is
01:08:24much more close to
01:08:26the heart of black people, and
01:08:28I was wondering, you know whether?
01:08:32Different art techniques
01:08:34are used in communications
01:08:36with different populations.
01:08:38Here in States and may
01:08:41do in treatment in PTSD.
01:08:46Yeah, so that's out that would be
01:08:48outside of my area of expertise and
01:08:50what I can tell you is the data around
01:08:54art therapy for PTSD has generally
01:08:56not found that it is effective,
01:08:58at least in reducing PTSD symptoms.
01:09:00Now that's not to say it can't work
01:09:03for somebody, or that it might not be
01:09:06a good adjunct to treatment, right?
01:09:08So you could think about that
01:09:10as a way of engaging someone,
01:09:12but then coupling it with one
01:09:14of these therapies for people.
01:09:16Focus on the trauma itself,
01:09:18but at least now most of that
01:09:20research has been done with children,
01:09:23not with adults.
01:09:25But in that review of the literature
01:09:27that IST SS, did they?
01:09:29Did not find that generally art therapy
01:09:32was effective for kids in reducing PTSD.
01:09:36So I think it's an interesting question.
01:09:39I don't know
01:09:40that, because yeah, I
01:09:42probably didn't didn't even think
01:09:44about the treatment of PTSD,
01:09:47but more like easing the communication
01:09:49as you described, so nicely. Yeah,
01:09:53absolutely. I mean,
01:09:54I think that's a great question of
01:09:57how do we engage people in K, right?
01:10:00How do we get people interested
01:10:03in the conversation?
01:10:04There is an investigator,
01:10:06for example, who's working with
01:10:08I believe Syrian refugees.
01:10:11And he is in Milwaukee if I'm correct
01:10:13and he's using yoga and dance as a
01:10:16way of engaging the community because
01:10:18what he found is they weren't willing
01:10:21to come in for these psychotherapies.
01:10:23But then once they're coming
01:10:25in for yoga and dance,
01:10:27then they're getting them
01:10:28engaged in the trauma therapies.
01:10:32Thank you. Yeah, no
01:10:35problem we have. We have time for
01:10:38probably one more question or comment.
01:10:42Another, any other questions or comments?
01:10:52Well, maybe that's a good place to stop.
01:10:56Thank you so much Deborah.
01:10:58This has been just a terrific
01:11:00presentation that you gave and
01:11:02also discussion afterwards.
01:11:04Really appreciate you doing this.
01:11:07Well, I really appreciate the
01:11:08invitation and the chance to have
01:11:10a conversation with all of you.
01:11:11I always leave these kinds of
01:11:13talks inspired and with new ideas.
01:11:15So for those of you in the audience,
01:11:17if you do have questions or
01:11:19want articles, let me know.