Alcohol & other drug studies

What effects pharmacology?

• Person (age, gender, individual health, cognition/expectations)

• Drug (how its taken, amount used, frequency of use, duration of use, drug interactions)

• environment (social factors, environmental tolerance)

What are the 2 ways drugs work?

Pharmacokinetics (how it moves through the body - to do with absorption, distribution, metabolism, etc.)

Pharmacodynamics (what it does to the body - to do with biochemistry, pharmacology and effects of the drug)

What is the agonist effect? and antagonist effect?

agonist - an increase or stimulation of the action of a neurotransmitter

antagonist - decrease of inhibition of the action of a neurotransmitter

What are the 3 classes of drugs?

Depressants - alcohol, heroin, benzos
Stimulants - nicotine, caffeine, amphetamines, cocaine
Hallucinogens - LSD, magic mushrooms

Key features of stimulants

• Increase body’s state of arousal

• accelerate central nervous system

• small doses: increase awareness and concentration, decrease fatigue and amplify positive moods'

• large doses: excessive anxiety, irritability, nervousness, insomnia, delusions and hallucinogens (drug-induced psychosis)

Key features of Depressants

• slow down brain and body

• may cause initial high/euphoria

• impair coordination

• some appear to cause emotional depression

• small doses: relaxation, drowsiness and loss of inhibitions

• large doses: can cause loss of consciousness, respiratory inhibitions

What are current key trends?

• smoking is decreasing

• vaping is increasing drastically

• risk alcohol consumption is decreasing for males, increasing for females

• underage drinking is decreasing

• females for more illicit drugs than males

• lower the socioeconomic status = more smoking

• older gen drug problem is meth, younger gen drug problem is weed

• excessive drinking is highest for concern

Waste Water Analysis

• nicotine and alcohol highest consumed substances across all states and territories

• cannabis is next most consumed drug

• capital cities: higher cocaine, heroin, fentanyl and ketamine

• regional: higher alcohol, nicotine, oxycodone, methylamphetamine, MDMA and cannabis

• ketamine was a record high in capital and regional (April)

• Fentanyl & oxycodone was record low in regional (April)

• alcohol was a record low in capitals (June)

According to DSM5 - How many criteria does SUD need to meet?

2 - Mild

3-5 Moderate

6+ Severe

How have drugs been used throughout history?

Ritualistic, ceremonial, medicinal

When is earliest drug/alcohol use in human history?

5000BC - beer in iraq/iran

Common elements of war on drugs approach:

• social menace

• moralist stance and generating a perceived need to protect vulnerable social groups (women, young people)

• portrayal of drug use as infectious

• increased criminal justice response

• increased media coverage

• underlying political agendas are often at work

What is ‘drug-related harm’ ?

harms that directly or indirectly affects the health, safety, security, social functioning and productivity of all Australians.
alcohol and drugs impacts on everyone

• health harms

• social harms

• economic harms

What is the spectrum of psychoactive substance use?

• beneficial (positive health, spiritual or social impacts, e.g. coffee, pharmaceuticals

• non problematic (recreational, casual or other use that has negligible health or social impacts

• problematic

• - potentially harmful - use that begins to have negative health consequences for individual, friends/family e.g. binge consumption, administration that increase harm

• - substance use disorders - clinical disorders as per DSM5 criteria

Harm misconceptions

1. the ‘addictive nature’ / dependence of a substance causes them to be harmful

2. harm most associated with illicit drugs? total burden of disease actually 7.6% tobacco, 4.1% alcohol, 2.9% illicit drug use (with opioid use accounted for higher illicit, 28%)

3. harms primarily affect the individual user - for every frequent drinker, 4 others negatively affected. children experience the most harm from it. 70% of crime related to substance use

Harmful use of alcohol

Individual

Family

• DV

• neglect own children

• spouse suffer the most

Social

• damage fabric of communities

Crime

• violence

• drink driving

What are the harm minimisation 3 main pillars?

• demand reduction

• supply reduction

• harm reduction

what is harm minimisation?

• policy and programs which prioritise the aim of decreasing the negative effects of drug use

• range of options aiming to improve health, social and economic outcomes for individuals and communities

Demand redcution

preventing uptake and/or delaying onset use of AOD. Reducing the misuse of AOD in the community and supporting people to recover from the dependence through evidence-informed treatment.
Strategies - delaying onset:

• school based drug prevention programs

• public awareness campaigns; reducing stigma, promoting help seeking

• reducing availability and accessibility

• advertising restrictions

strategies - supporting recovery:

• treatment services, counselling and brief interventions

• diversion initiatives

• rehab

Supply reduction

preventing, stopping, disrupting or otherwise reducing the production and supply of illegal drugs; and controlling, managing and/or regulating the availability of legal drugs.

1. control licit substances and precursor availability

2. prevent and reduce illicit substance availability and accessibility

e.g. regulating or disrupting production - border control, policing. age restrictions. scheduling of drugs

Harm reduction

reducing the adverse health, social and economic consequences of the use of drugs, for the user, their families and the wider community

reduce risk behaviours

• encourage safer behaviour

• reduce preventable risk factors

safer settings - can contribute to reduction in health and social inequalities among specific groups
e.g.

• needle and syringe programs

• take home naloxone

• drug checking

• counselling and brief interventions

Young People - Smoking

prevalence of tobacco smoking among younger age groups is decreasing, driven by a higher proportion of young adults not taking up smoking.

• 98% of people aged 14-17 had ever smoked, increasing from 82% in 2001.

• about 4 in 5 (83%) of people aged 18-24 had never smoked

age of initiation is increasing (getting older)

Young people - Alcohol

Age of initiation increasing (14.7 to 16.1)

increase in abstinence (14-17 increased from 39% to 70%. 18-24 increased from 13.1% to 23%).

18-24 most likely age group to risky drink. This trend is reducing

increase in younger women drinking

risky drinkers tend to start 2 years earlier.

Young people - illicit drugs

• cannabis, cocaine, & ecstasy are drugs most commonly used by people 18024

• average age of initiation is 19.5

• recent use of cannabis has declined

• alcohol use and illicit drug use highest burden of disease in males aged 15-24, second and third leading causes in females.

Older people

• tobacco is leading risk factor for males and females aged 65-74 and 75-84 and for males aged 45-64

• 70+ highest cohort who drink daily

• risky drinking is less likely 70+ lowest cohort and females in their 50’s, males in their 60’s least likely to risky drink

• pharmaceuticals - 50+ are highest, getting prescribed opioids, benzo’s

People who inject drugs

• higher risk of fatal overdoses

• methamphetamine was highest injected, followed by heroin

• trend is slightly decreasing

Cis Gendered Women

• higher rates of prescription use

• develop problematic use more quickly

• long-term downward trend in tobacco smoking females aged 14+

• long-term downward trend in alcohol consumption for women

• increase in illicit drugs in women between 20’s-40’s

biological differences:

• intoxication occurs with less alcohol intake

• metabolise alcohol differently

• develop cirrhosis of liver more rapidly

social differences:

• increased stigma associated with use/misuse

• more often caring for children

• cultural differences regarding status in society

women facts

• more likely to have experienced child maltreatment and ongoing adult trauma such as DV

• have a history of self-harm or attempted suicides (particularly due to childhood abuse)

• have first used with partner

• have primary care of children

• lower rates of employment

• poorer mental health history (higher cases of most psychiatric diagnoses such as anxiety, depression, eating disorders, PTSD and BPD)

• more likely to self medicate with AOD

• have greater vulnerability to relapse than men

Aboriginal and Torres Strait Islander

• gap in life expectancy is now about 10-12 years earlier than non-indigenous

• higher rates of infant mortality

• tobacco use higher amongst first nations people but is downward trend

• alcohol abstinence has increased, although more likely to risky drink as well (downward trends)

LGBTQIA+

• rates of AOD use by LGBT people is 2-4 times higher than AOD rates by heterosexual people

Major Risk Factors

before birth: social disadvantage, family breakdown, genetic influences, maternal smoking & alcohol use, SES, trauma, genetics.
Primary school: parent neglect/abuse, aggression, early school failure

Family: parental role modelling, family relationships/support

Education: academic failure (could be contributor or result of), timing of failure (e.g. year 1 does not predict later delinquency vs year 5 that does.

secondary school: low involvement in activities with adults, positive media portrayal, peers who use, parental AOD problems, sensation seeking and adventurous personality

personality: rebellious, non-conformity, low sense of responsibility, resistance to authority

age of initiation: earlier initiation increases risk of later abuse

Macro-environment: society and cultural.

Adulthood: unemployment, mental health problems

Retirement age: loneliness, losing a spouse, poor health, retirement

SES stats

Daily smoking

• Richest least likely

Vaping

• Richest more likely

Risky alcohol

• Richest more likely with 2nd lowest

Illicit drug use

• Richest most likely

Protective factors

before birth: born outside of australia

ethnicity: family cohesion, rules and cultural norms (could also be a risk factor, low SES, family trauma, social isolation. Indigenous is risk factor)

Primary school: easy temperament, shy and cautious, social and emotional competence

education: pro-social contact (inc. with adults), minimises boredom, enhances intelligence

secondary: attachment to family, low parental conflict, religious involvement, parental communication

adulthood: good health, social support

general: positive family relationships, healthy attachments, proactive problem solving, career goals. connection.

Prevention levels

primary: preventing uptake - preventing non-users starting or delaying first use

• e.g. supply reduction methods, education on harms to developing body, school based education programs

secondary: preventing harm - reducing risks to experimental/social users and avoiding transition to more regular use or possible harms

• e.g. education on risks of addiction, advice on route of administration options

tertiary: reducing harm - reducing use or potential harms among regular users

• e.g. NSP’s, controlling drinking, drink driving campaigns

Prevention targets

Universal: targeting whole populations

• national campaigns, advertising programs

selective: subgroups with above average risk

• school-based programs, alcohol-free communities

indicted: individuals with detectable symptoms

• counselling, advice lines, educational pamphlets

According to DSM 5, substance use disorder is defined as?

clinically significant impairment or distress and characterised by >2 of the criteria in past 12 months;

1. consumption in higher qualities and/or for longer duration than intended

2. persistent urge or multiple attempts to reduce use

3. time and effort devoted to the substance

4. cravings or strong desire to use the substance

5. impairment of responsibilities and duties

6. continuing to use, even when it causes problems in relationships

7. avoidance or reduced time devoted to important activities

8. ongoing use even when it puts you in danger

9. consumption despite awareness of causing/worsening a health problem

10. needing more of the substance to get the effect you want (tolerance)

11. development of withdrawal symptoms, which can be relieved by taking more of the substance

Moral model

‘Original’ model of addiction. Addiction was viewed as a moral failing & sign of personal weakness. Addiction resulted as lack of willpower or moral integrity rather than biological or psychological factors.

Spiritual model

Suggests SUD stems from lack of spiritual fulfilment or disconnection from higher power. Believe in order to overcome addiction, must establish deeper connection with everyone and everything.

Criticisms/implications for moral & spiritual models.

Crit: lack of scientific evidence (esp. moral), stigma against individuals with addiction and barriers to treatment, reinforces the tendency toward self-blame

implications: policy influences (some drug policies still rooted in moral perspectives leading to criminalisation rather than treatment), 12 step programs emphasise spiritual awakening and higher powers, mindfulness and spiritual healing, cultural and indigenous perspectives

Biological theories: Disease model of addiction

• views addiction as medication condition rather than moral failing

• changes in brain structure and function, particularly pre-frontal cortex

• addiction shares characteristics with diseases like diabetes, including genetic predisposition, environmental triggers & need for long term management

• disease of addiction is irreversible. cannot be cured, only treated by lifelong abstinence

Biological theories: Genetic theories

• evidence from twin studies suggest strong genetic component

• heritability rates of 40-60% for alcoholism

• genetic & environmental. DRD2 gene linked to dopamine receptor sensitivity influencing addiction risk. OPRM1 gene effects opioid reception function

Biological theories: neurobiological theories

role of neurotransmitters:

• dopamine (reward & pleasure)

• serotonin (mood regulation)

• glutamate (learning/memory)

• GABA (inhibition)

these play key roles in addiction

Biological theories: Neuro-adaption

• refers to change in the brain that occurs to oppose a drugs acute actions after repeated drug administration

• long-term drug use alters brain function, weakening executive control & increasing compulsive behaviours

• when drugs repeatedly administered, changes occur in the chemistry of the brain to oppose the drugs effects

• when drug use is discontinued, adaptions are no longer opposed; brain’s homeostasis is disrupted

• this hypothesis argues that tolerance and withdrawal are result of neuroadaptation

• AOD use continues in attempt to avoid symptoms of withdrawal

Criticisms and implications: Biological theories

Criticisms:

• some argue that is reduces personal responsibility and underestimates the role of social and psychological factors

• primarily focused on abstinence - which is not suitable for all people

Implications for treatment:

• supports medical interventions such as medication-assisted treatment, and harm reduction strategies

• substance use becomes a health issues not just a legal issue

• offers a treatment approach (abstinence) that works for some

• removed some of the shame often felt by people with SUD

Psychological theories: Psychodynamic perspectives

• originated with Freud, still used today

• Freud suggests unresolved conflicts and self-medication for anxiety, depression, trauma

• basic philosophy is that we can link our problems to our childhood and how we cope as adults

1. unconscious processes that govern the id, ego, & superego (Freudian)

• Fixated at the "oral" stage

• Id - drive reduction theory

• Ego - "self-medication”

2. attachment styles (Bowlby)

view addiction as more of self-regulation disorder

• inability to recognise and regulate feelings

• inability to establish and maintain a coherent, comfortable sense of self

• inability to establish and maintain comforting relationships

Psychological theories: Personality theory

Group of distinct personality characteristics that distinguish alcoholics/drug users from other individuals

predisposing factor “addictive personality”

characteristics of personality attributed to addicted personality do not predict addiction, but rather result of addiction.

personality predictors of drug use:

• behavioural disinhibition (impulsivity)

• emotional negativity (negative mood, depressive PD)

• sensation seeking

• non-conformity

• social isolation and tolerance for deviance

• avoidance

traits: sensation- seeking and neuroticism increase risk, while conscientiousness may be protective

Psychological theories: Behavioural

only considers observable/measurable behaviour

behaviour is consequence of learning

two central notions that substance use is:

• learned and

• is functional

four main types of conditioning

• classical conditioning

• operant conditioning

• modelling

• tension reduction

Psychological theories: Behavioural - classical conditioning

sights, smells, and sounds consistently associated with drug use elicit physiological and psychological responses that lead to drug seeking behaviour

• Conditioned Stimuli (CS) - cues and triggers

• Conditioned Response (CR) - physiological and psychological responses

Psychological theories: Behavioural - operant conditioning

focuses on reinforcing properties of drugs, and the likelihood of people repeating immediately pleasurable experiences (and avoiding unpleasurable experiences)

three main reinforcement types:

• positive reinforcement (drugs can cause pleasurable sensations)

• negative reinforcement (use to remove aversive experiences, “I drink beer cause it removes my anxiety”)

• punishment (“I drink beer, I get locked up by police”)

Psychological theories: Behavioural - Modelling

• people learn favourable attitudes and expectation about drinking based on how the behaviour is modelled

• increases the likelihood of pleasant experiences learned from others

• maintenance associated with past associations with drug-taking environments/situations.

What is ABC?

A - Antecedents

• triggers: situations (e.g. home alone at night), thoughts (“I have no friends”), feelings (tired, sad anxious)

B - Behaviour

• something the person does (e.g. drinking alcohol)

C - Consequences

• reinforces (outcomes that maintain the behaviour), payoffs (immediate - feelings of relief, relax)

Psychological theories: cognitive & CBT therapy.

suggests that thoughts influence emotions and behaviours

focuses on thoughts/beliefs, and impact on behaviours and feelings

the way people interpret specific situations influences feelings, motivations and actions

maladaptive thought patterns, such as irrational beliefs and cognitive distortions, can lead to and maintain substance use

layers of beliefs - core beliefs / schemas

expectancy theory (bandura)

• addictive behaviours chosen over other behaviours due to our expectancies

• two specific cognitions: outcome expectancy - beliefs about effects and outcomes of using. Self-efficacy - belief in one’s own ability to effect change.

CBT therapy

Based on idea that thoughts, emotions, and behaviours are interconnected and that changing thoughts and behaviours can reduce substance use.

Research supports CBT as one of most effective treatments for substance use, including lower relapse rates.

• functional analysis - identifying triggers and consequences of substance use

• coping strategies training - learning new ways to handle stress without substances; teaching ways to handle triggers and cravings

• self-monitoring - tracking thoughts and cravings to understand patterns

• cognitive restructuring - replacing drug-related thoughts with healthier beliefs

• behavioural experiments - testing new behaviours in real-life situations

• relapse prevention model - identifying high-risk situations and using cognitive and behavioural strategies to prevent relapse

Third wave psychotherapies, contextual CBT’s

• acceptance and commitment therapy

• dialectical behavioural therapy

• mindfulness-based relapse prevention

key differences:

• emphases on mindfulness and acceptance strategies to reduce the impact of internal triggers on substance use behaviour (e.g. altering context and functions so cravings, distress, etc. less likely to lead to substance use)

• taking broad, functional approach to treatment, emphasising motivation and values-based strategies

• transdiagnostic - effectively target key psychological problems commonly comorbid with substance use including depression, anxiety and self-stigma

Social and system theories

determinants of behaviour are based on an individuals role within a system.

focuses on society as a whole and not just on individuals

• family and other systems have role in initiating and maintaining substance use

• cultural norms and substance use - societal acceptance influences usage patterns

• socioeconomic status -poverty and stress increase vulnerability

Social learning theory (bandura)

• observational learning from family, peers, and media plays significant role

• e.g. adolescents who view substance use in positive light, whose peers use drugs

Tension reduction theory

Tension in society.

Demands relief

• problem: of elimination of reduction of conditions that create tension

• problem: of finding a mode for relief of tension

Motivation and change theories

• “transtheoretical”

• increase clients awareness of potential problems caused, consequences experienced, and risks faced as a result of behaviour in question

• clients do not necessarily enter treatment committed to action and making changes.

• Motivational interviewing - intrinsic motivation is a necessary and sufficient factor to initiate behaviour change

Biopsychosocial model

• proposes that drug use is influenced by a combination of biological, psychological and social factors

• moves beyond purely medical or moral perspective by integrating multiple influences that contribute to substance use behaviours

3 distinctions of dual diagnosis

Heterotypic/homotypic - e.g. mental health and physical disorder vs 2 mental health disorders

Concurrent/successive - e.g. alcohol dependence and depression at the same time vs panic disorder in teenage years and cannabis use in twenties

Continuum - e.g. ranging from mild symptoms to severe disorders

How likely is dual diagnosis

DD prevalence estimate range from 30-90%

• depends on diagnostic criteria (severe/ PD, sub-clinical)

• higher prevalence in A&D settings and higher in treatment settings

• more prevalent for Indigenous Australians

• Also higher among females

Incidence of dual diagnosis in A&D settings

• 48% of females with alcohol use disorder also have anxiety affective disorder or drug use disorder

• 34% of males with alcohol use disorder had another mental disorders

Most commonly seen disorders in AOD treatment settings

Anxiety - 12-91%

generalised anxiety disorder - 1-75%

depression - 27-85%

PTSD - 5-66%

ASPD - 2-72%

BPD - 16-48%

bipolar - 4-53%

OCD - 1-52%

psychotic disorders - 2-41%

methamphetamine & DD

Aus survey of people with meth dependence

• % had major depression or anxiety disorder in the past year

• approx. 30% of dependent users experience psychotic eps each year

Incidence of DD in MH

• 17% with affective disorder also had alcohol use disorder

• 16% with an anxiety disorder also had alcohol use disorder

How could drugs cause depression

depressants - general depressant effect

• alcohol - interferes with medications, long term effect on relationships, employment, health, etc.

• cannabis - long term use may cause ‘depression-like’ symptoms - hypothesised ‘amotivational syndrome’

• opioids - lifestyle related factors associated with opioid dependence

stimulants -

• existing depression may get worse when coming down

• common in the months following cessation

• use/abuse may worsen the sleep/wake cycle

How could drugs cause Anxiety?

Depressants - agitation, anxiety, and irritability common features of withdrawal

• alcohol - alcohol related problems can create new worries

• hangxiety - more trouble regulating emotions, heightened stress, brain activity involving dopamine is lower

• cannabis - paranoia a common symptom of intoxication

• benzo’s - withdrawals feel so much like anxiety

stimulants -

• chronic use - anxiety states and panic

• high doses - obsessive cognitions and compulsive behaviours

How can drugs cause psychosis?

reinforcing effects of drugs related to dopamine.

Cannabis

• precipitate psychotic episodes

• some evidence suggests causal link

• pharmacology and potency (THC vs CBD)

• known to increase rates of hospitalisation, psychotic relapse and psychotic symptoms

Alcohol

• negative symptoms worsen and affects treatment

• non-compliance with medication

• higher relapse rates

stimulants

• may directly cause psychotic episodes

• amphetamine psychosis - brief psychology reaction that may last for several weeks

• formication - feels like insects under skin

• stereotypy - repetitive behaviours

How could MH cause A&D problems

• Depressant drugs used as a form of “self-medication” of anxiety symptoms

• stimulant drugs used as self-medication of depression

• pain relieving drugs to manage chronic emotional pain/trauma (opioids and sedatives commonly linked to a history of trauma, up to 90%)

• personality characteristics may lead to use in greater quantities or greater frequency

• any substance use disorder occur in over half of individuals with bipolar I disorder

Shared risk factors

factors may increase risk of both AOD and MH conditions

• lower socioeconomic status

• cognitive impairment

• conduct disorder in childhood

• antisocial personality disorder

DD - issues for the client

• Greater severity of disorders (more hallucinations, depressive symptoms and suicidal ideation, relapse risk increased, rehospitalisation, effects on medications)

• loss of support networks (unstable accommodation, family/relationship issues, double stigmatisation, harder to access service, lack of education, legal issues)

• poorer self-care (increased risk taking behaviour, less compliant with medication, sleep, diet, exercise

Issues for treatment services

• complex presentations (more than one drug use/mental health issue, psycho-social issues)

• diagnosis are often unclear (lack of screening, misdiagnosis)

• lack of dual expertise or awareness of issues (lack of confidence in DD)

• perceived as added work vs more effective work

• lack of flexibility in service provision (appointment based models)

• confronts clinicians’ own issues?

diagnostic issues

Schizophrenia:

• positive symptoms: hallucinations, delusional thinking, disorganised speed

• negative symptoms: flattened affect, lack of motivation, poverty of speech

Issues for treatment services - Assessment

• accurate history crucial: family history of MH problems, order of disease onset

• better screening

• cease drug use before assessing: 3 months abstinence is considered adequate

• get lots of experience in both services

Issues for treatment services - Treatment

• engagement and follow-up processes

• conflicts in philosophies/perspectives of different services: Attitudes, harm minimisation vs zero tolerance, difference service entry requirements/exclusions, reluctance to work with DD, what to treat first? (A&D or MH), service priorities

• may not benefit from standard interventions: poorer treatment response and outcomes

Relationships between MH & SUD

• use of substances causes or exacerbates an underlying MH problem

• MHD lead to substance use and abuse

• MHD and SUD develop together and reinforce each other

• both MHD and SUD develop somewhat independently of each other due to common causes of risk factors (e.g. trauma/adversity/etc.)

• regardless of relationship, usually become inter-connected over time and result in a worsening clinical picture

Treatment models

• sequential

• parallel

• third specialist service

• collaborative

• integrated

Treatment more effective when:

• integrated

• focused on maintaining motivation & promoting treatment engagement

• assertive case management

• extends over several months

• based on “no wrong door” approach

Association between trauma & AOD

• 90% of individuals accessing AOD services have experienced at least one traumatic event

• majority have experienced multiple traumatic events

• up to 2/3 would meet criteria for PTSD

• many clients continue to live in environments which expose them to chronic toxic stress

• AOD clients with trauma symptoms are not adequately recognised and treated

Trauma and SUD

• poorer social &occupational functioning

• higher rates of inpatient treatment

• greater risk of relapse

• poly substance use

• chronic health conditions

• more co-morbid psychiatric disorders

• non-suicidal self-injury and suicide attempts

• less effective coping strategies

• child safety involvement

• more chronic and severe symptoms

• higher rates of service utilisation

• homelessness

• family violene

• more criminal justice systems contacts

Different types of trauma

Single incident trauma:

• experiences in which we feel our lives are threatened (e.g. physical or sexual assaults, serious accidents or illnesses)

• witnessing or being exposed to the effects or details of someone else being harms

complex trauma:

• refers to multiple or combined traumatic events that mainly occur in childhood

Response to trauma

when frightened, threatened or harmed, the brains ‘alarm’ system is activated. This triggers our sympathetic nervous system to turn on the “fight, flight, or freeze” response

survival responses can also include:

• fawning

• shutdown/dissociation

• flop

range of factors mediate a person’s response to trauma

• age/development stage at which abuse/trauma occurred

• frequency, duration, nature and predictability of the trauma

• level of evasiveness of the trauma

• degree of associated violence and physical harm caused

• nature of the relationship with the abused (e.g. caregiver/trusted adult vs stranger)

• cultural and systemic context in which the trauma occurred

• meanings attached to trauma experienced

• the degree to which the responses of adults and organisations to the knowledge of traumatic events are validating vs disbelieving

Trauma and PTSD

• 75% of general population experience at least one traumatic event in their lifetime & will be able to recover without too much difficulty

• small % are not able to return to normal functioning & will suffer persistent stress symptoms after the event

• if severe enough = PTSD

• 11% of Australians will experience PTSD in their lifetime (women 14% twice at risk men 8%)

PTSD

may develop following exposure to type 1 traumatic event. symptoms must have persisted for more than one month and include:

• intrusion symptoms (recurring, unwanted and uncontrolled memories of the event that feel as thought they’re reliving it)

• persistent avoidance of stimuli associated with the trauma (could be external - avoiding reminders of people, place, or things that are associated with the traumatic event. Or internal - trying not to think about or feel anything associated with the event.

• negative alterations in thinking and mood, negative thoughts about self and others, strong emotions (anger, guilt, fear) and feeling disconnected from others and engagement with the world

• alterations in arousal and reactivity - hyperarousal (i.e. being on edge, or easily startled), hypervigilance (i.e. looking out for threat or something bad that could happen) , irritability, poor concentration, disturbed sleep

CPTSD - diagnostic

All diagnostic requirements for PTSD are met with additional difficulties, characterised by severe and persistent:

• problems in emotion regulation

• beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic events

• difficulties in sustaining relationships and in feeling close to others

Effects of CPTSD

If developmental, can cause lasting alterations:

• developmentally frozen

• sensitivity to stress

• affect dysregulation

• impulsivity

• sense of self build around shame

• lack of agency

• threat based schemas / neg bias

• cycle of chaos

• avoidant coping strategies

• helplessness/hopelessness

• interpersonal difficulties

• dissociation

3 categories of ACE’s

• abuse

• household challenges

• neglect

ACE long lasting effects

• health (obesity, diabetes, depression, suicide attempts, STDs, heart disease, cancer, stroke, COPD, broken bones)

• behaviours (smoking, alcoholism, drug use)

• life potential (graduation rates, academic achievement, lost time from work)

ACE’s and AOD problems

• more ACEs you’ve had, more susceptible you are to early initiation of alcohol and other drug use and continued and problematic use into adulthood

• ACEs were found to account for one half - two thirds of serious drug use

• for each additional event experienced, the odds of developing a drug problem increased by 30-40%

Effects of childhood trauma on the brain and boy

• immune system dysfunction implicated in association between childhood trauma and adult psychiatric and physical disorders

• dysregulation of hypothalamic-pituitary-adrenal (HPA) through exposure to chronic stress developmentally

• endocrine features of PTSD include abnormal regulation of cortisol and thyroid hormones (both hyper and hypo cortisol levels)

• decreased availability of cortisol, as a result of or in combination with abnormal regulation of HPA axis, may promote abnormal stress reactivity

• neurochemical features of PTSD - abnormal regulation of catecholamine, serotonin, amino acid, peptide, and opioid neurotransmitters, each of which is found in the brain that regulate/integrate stress and fear responses

Symptoms as threat responses & adaptations to cope

Self-harm, bingeing/purging, AOD use, impulsivity, denial - regulating overwhelming emotions

grandiosity, entitlement, perfectionism, aggression - preserving identity and self-esteem

self-starvation, rituals, violence - maintaining a sense of control

hypervigilance, insomnia, flashbacks, suspicious thoughts, isolation, aggression - protection from danger

Self-regulation hypothesis

• AOD can give relief from unpleasant trauma related thoughts and feelings (e.g. hyperarousal, insomnia, intrusive thoughts, emotional distress)

• the pain relieving and numbing effects of substance (particularly CNS suppressants such as alcohol, cannabis, opioids & benzo’s) can reduce unpleasant symptoms but perpetuate and exacerbate high levels of arousal caused by withdrawal

• this relationship can maintain PTSD symptoms and reinforce ongoing substance use and dependence

• substances may also serve other functions such as providing feelings of pleasure and social connection

High-risk hypothesis

• suggests that the lifestyle associated with alcohol and drug use increases the person’s risk of experiencing trauma due to factors such as intoxication and engagement with dangerous environments associated with crime

Susceptibility hypothesis

• proposes that some individuals struggle with higher levels of arousal and anxiety (in conjunction with ineffective coping strategies) which places them at greater risk for both PTSD and AOD problems

• helps to explain connection between adverse childhood experiences/complex trauma and a higher risk for developing problematic AOD use in adulthood

Common factors hypothesis

This rationale suggests that there may be common causal influences driving both PTSD and AOD problems such as:

• genetic risk

• personality traits such as impulsivity

• adverse environments

Cycle of trauma and addiction

• Trauma/adverse life experiences

• emotion dysregulation, PTSD, negative self beliefs, social disconnection

• self-medication - AOD use

• life complications; increased pain, shame

• more self-medication leading to greater severity of AOD problems

when people who have experienced CPTSD engage with services they may:

• be highly sensitive to minor stressors (or triggers)

• react to perceived imposition of power or coercion

• struggle to feel trust in therapeutic relationship

• easily perceive judgement or criticism

• misunderstand boundaries

• have difficulties with time and schedules

PHASE BASED TREATMENT MODEL FOR CONCURRENT PTSD & SUD

Phase 1: safety and stabilisation-

• development of strategies of self-management and emotion regulation

• psychoeducation regarding the effects of trauma and interaction with alcohol & drug use

Phase 2: trauma processing-

• review and re-appraisal of trauma memories usually involving exposure based psychological treatment

Phase 3: integration and reconnection-

• consolidating gains, building independence and community supports

Principles of Trauma informed care

• safety - physical, emotional, environmental, cultural, systemic

• trustworthiness - clarity, consistency, interpersonal boundaries

• choice - maximising choice and control

• empowerment - prioritising empowerment skills

• collaboration - maximising collaboration, sharing power