Research Notes - Articles on Comorbidity & PTSD - Various

 For this week, I looked at various Psychological studies that focused on Comorbidity and PTSD. I started out by looking at Comorbidity clusters in veterens for a (admittedly narrow) overview of what areas of comorbidity seem to be grouped together. Next I moved on to looking at more specific instances of common comorbidity. 

I found that substance abuse was a big topic in many of these studies, assumably because substance abuse is a massive issue that affects people all over the country, and mitigating it is a top priority. Other comorbidity I looked at included co-morbid bipolar disorder, schizophrenia, and ADHD. In all cases, the results of the trial were consistent: People who suffer from PTSD are at a higher risk of not just these other co-morbid issues, but also tend to suffer more severe symptoms from these various areas. 

Please find my research notes below:

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Complex Comorbidity Clusters in OEF/OIF Veterans: The PolyTrauma Clinical Triad & Beyond

 by Mary Jo V. Pugh, et al.

Pugh, Mary Jo V., et al. “Complex Comorbidity Clusters in OEF/OIF Veterans: The Polytrauma Clinical Triad and Beyond.” Medical Care, vol. 52, no. 2, Lippincott Williams & Wilkins, 2014, pp. 172–81,
 Looking at the Polytrauma Clinical triad (a combination of traumatic brain injury (TBI), PTSD, and Pain) and how different comorbid issues create identifiable clusters. 
    -    This can help identify which other comorbidities are most likely to pop up in certain types of PTSD for better overall treatment. 
    -    The study also chose to look at chronic conditions (diabetes, heart disease) and see what clusters those fell in to better recognize the need for more physical treatment. 
The study wants to go beyond looking at just other mental illnesses that affect those with PTSD, and include the physical  burdens
GOAL: ID patterns of physical & mental comorbidities to look out for. 


HYPOTHESIS: Looks at 3 main health concerns:

    1. Mental Health
    2. Pain
    3. Chronic Disease
To do this, they identified patients fitting the criteria for comorbid conditions from within a pool of existing VA Veterans already seeking treatment 

Research suggests that clusters of PTSD patients with comorbidity do not create a picture of any one typical PTSD patient, but several paths that PTSD patients can tend towards. 

    -    The research being done here  may identify those who are more at risk for getting a chronic disease, such as heart disease, though they made a note to admit that the chronic disease risk was shown to be much higher in older patients than younger, questioning whether these chronic illnesses stemmed from the PTSD itself, or aging.
            -     There was no similar correlation to mental comorbidity, and the spread was much more evenly spread than chronic disease. 

Additionally, it was found that there was no pattern to how pain was affected in terms of PTSD comorbidity unless it was paired with a psychiatric comorbidity. It seems that for there to be a pattern, a mental disorder must be a part of the cluster, or the correlation is not there. 

Depression was recognized as a very significant comorbidity to PTSD, and contributes the most to whether or not PTSD will have an adverse outcome. 

Some reservations with the data are stated:

The most important of these focuses on the fact that the data only accounts for veterans who have actively sought out the VA services for help in managing their PTSD and other comorbid issues. 
    -    Important as well is that the samples are not entirely clean, and while they deal with veterans of the most recent wars, there are some veterans included that could have sustained other conditions through their participation in earlier wars.
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Substance Abuse & Posttraumatic Stress Disorder

by Kathleen T. Brady, et al.

Brady, Kathleen T., et al. “Substance Abuse and Posttraumatic Stress Disorder.” Current Directions in Psychological Science, vol. 13, no. 5, [Association for Psychological Science, Sage Publications, Inc.], 2004, pp. 206–09,

PTSD & Substance Abuse

PTSD and substance use disorders (such as substance abuse & substance dependancy) commonly co-occur (comorbidity). 
PTSD - "characterized by symptoms that persist for at least 1 month following the exposure to a traumatic event" p. 1

Lifetime PTSD - refers to an individual who has been diagnosed with PTSD at one point in their life, but who may not suffer from current PTSD. 

Symptoms of PTSD are divided into 3 catagories:

    1. Avoidant Behavior - avoiding activities, places, people who remind one of trauma
    2. Intrusive Symptoms - flashbacks, unwanted thoughts, nightmares
    3. Arousal Symptoms - exaggerated reflex, restless sleep, hyperactivity of the thalamus

Avoidant / Intrusive symptoms are important for Substance Abuse comorbidity, as substance abuse is often used as a method of escaping these symptoms and avoid memories of trauma.


Men with PTSD are 5x as likely to have a substance abuse issue. 
Women are 1.4x as likely
    -    The main substances are alcohol and drugs such as Cocaine and Opiods
However, Out of people who abuse substances, Women were more likely than Men to also have PTSD. 

 Individuals with PTSD and SUD suffer most often from interpersonal trauma. 
    -   Abuse, neglect, sexual assault, emotional abuse
    -    Most individuals report multiple instances of trauma

Hypotheses of the Study:

1.     Self- Medication 
        -    "traumatized individuals attempt to use substances in order to dampen traumatic memories, or                     to avoid, or escape from other painful symptoms of PTSD" - p.207
        -    Drugs and alcohol inhibit  the amygdala and dampen arousal of in the thalamus. This is the                         same system responsible for trauma response. The ability of these drugs to cut off the                             communication would act as a viable form of self medication to keep trauma survivors out of                   a trauma response mindset. This supports the Self Medication hypothesis.  
        -    The downside to this type of self medication: Withdrawal symptoms exacerbate the fight or                     flight responses in the thalamus by activating it when coming down, inducing PTSD panic                     responses and even heightening those symptoms.
2.     High Risk 
        -    "Individuals with SUD (substance use disorders), because of high risk lifestyles, are likely to                     experience trauma, and are, therefore, more likely than the general population to develop                         PTSD." -p.207
3.     Susceptibility
        -    "Substance use increases an individual's susceptibility to devoloping PTSD following a trauma"                 -p.207
                -    It appears as though the opposite of this is true according to trends. Those who develop                         PTSD appear to be more susceptible to developing substance abuse issues, though                                 exposure to traumatic events that did not result in PTSD do not.
                -     It is the development of PTSD, not the experience of trauma, that affects how susceptible                       someone is to getting a SUD. 
        -    Common susceptibility factors also looked at, and it was determined that there is no genetic                    link or vulnerability  common to PTSD and SUDs. 
                -    There is, however, some evidence to suggest that neurobiological relationships could play                         a roll in the development of both. 

You can tell that this section of the study is out of date, as the study, published in 2004, is pushing the idea that CBT (cognitive behavioral therapy) is one of the most viable treatment options to help patients with comorbid PTSD and Substance use disorders. 
    -    Even the article here states that the symptoms of PTSD make CBT non-viable as a large amount of drop out participants cannot complete the CBT treatments, and getting to caught up in the histories of their own trauma can cause patients to relapse easily into substance abuse. 
Additionally, while the study does advocate for psychopharmacology as an option to help treat patients with substance abuse issues by giving them medications to help stop the symptoms of PTSD, it does not offer any further insight into modern treatments which were in very experimental stages at the time of its publishing. 
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Trauma exposure and post-traumatic stress disorder in bipolar disorder

by HJ. Assion, N. Brune, N. Schmidt, et al. 

Assion, HJ., Brune, N., Schmidt, N. et al. Trauma exposure and post-traumatic stress disorder in bipolar disorder. Soc Psychiat Epidemiol 44, 1041–1049 (2009).
Bipolar PTSD patients have a higher risk of exposure to physical violence, neglect, sexual assault and familial interpersonal violence. 

PTSD has been shown to exacerbate symptoms associated with Bipolar disorder. 

While PTSD increases the risk of Bipolar disorder, a small support network, in combination with the length of exposure to trauma, and socio-economic status increase that risk by a fair margin.

Mania, which is characterized by a "high" where the patient feels abnormally confidant, and have a high arousal level. Those who have manic episodes are at increased risk to develop PTSD following even an indirect trauma. 

GOAL: The goal of this study was to find out if Bipolar disorder created an increased risk of developing PTSD following trauma. 

All participants were European, and most were of caukasian, german descent. Because of this, this study can only serve a small subset of the population. 
    -     all participants were clinically diagnosed with Bipolar disorder and divided into 3 groups:
                -     Those diagnosed with lifetime PTSD
                -     Those self diagnosed with PTSD
                -    Those without PTSD. 
    -    To determine if participants had PTSD, all participants took a self diagnostic PTSD test (PDS aka the Traumatic Stress Diagnostic Scale), and then were followed up with a clinical PTSD test (CAPS aka the Clinician Administered Post-traumatic Stress Disorder Scale)

Findings of Note

1. A significantly higher probability of having one alcohol dependent parent was found in patients with BP and PTSD, as well as a higher probability of having suffered from severe parental violence. 

2. There were no significant differences between the three groups except in terms of the likelyhood of acute depression, and psychosocial functioning. 

3. Bipolar patients were found to be 2x as likely to develop PTSD after a traumatic event than the general population

4. Unlike other studies, this one did not confirm the findings that comorbid PTSD and bipolar disorder led to an increased number of manic/depressive episodes, a higher rate of suicide attempts, or an increased rate of other comorbities, or even a higher incidence of alcohol or substance abuse.
    -    A similar study to this one showed that Americans (who used a much more diverse pool of                         participants in terms of race, ethnicity, age etc.) did find correlations between a lot of these                     issues.  
5. An odd correlation found was that Bipolar PTSD patients had a much higher number of siblings than others with Bipolar disorder. This suggests to the researchers that "an increased number of siblings may contribute to a family atmosphere with a more stressful emotional setting, which may contribute to an increased probability for exposure to trauma." p.1047
Although I ended up looking for a more thorough and recent study delving into how PTSD related to Bipolar disorder, but unfortunately, most of these articles are hidden behind paywalls, or else currently under peer review, as this study ultimately did not say a ton about what the effects of such a comorbidity would be, and what it would actually do. 
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Early life stress and PTSD symptoms in patients with comorbid schizophrenia and substance abuse

by G Schellar-Gilkey, K Moynes, I Cooper, C Kant, & AH Miller

Scheller-Gilkey G, Moynes K, Cooper I, Kant C, Miller AH. Early life stress and PTSD symptoms in patients with comorbid schizophrenia and substance abuse. Schizophr Res. 2004 Aug 1;69(2-3):167-74. doi: 10.1016/s0920-9964(03)00188-9. PMID: 15469190.

Schizophrenia & Substance abuse & PTSD

Substance abuse is a prevalent problem in schizophrenic patients, as it is believed that both substance abusers and people with schizophrenia are predisposed to suffer traumatic events. 

Patients who had both SUDs and Schizophrenia were found to have a significantly higher frequency of childhood traumatic events  and much higher depression scores. 

Early Life Stress
    -    It was found that early life stress is one of the highest contributors to substance abuse, and particularly early childhood abuse and sexual abuse has been the most powerful predictor of later psychiatric disorders, including psychosis. 

Earlier work has shown additionally that early life stress is associated with PTSD symptoms and substance abuse in patients with schizophrenia. 

The Study

    -    Divided up by substance abusers or non-substance abusers, all with diagnosed schizophrenia. 
    -    To keep tabs on accuracy, urine tests and other drug tests were used for the purpose of determining how much substance abuse was occuring in patients, rather than relying on the patients with the potential for psychosis to lie
            -    Patients were recommended for the treatment so that the researchers could count on patients being willing particpants unlikely to grow paranoid with the goals of the research. 
    -    All participants were impoverished city residents. 

Interestingly, the most common traumatic event reported among members of the study were the death of a close friend or relative, followed by those who had experienced sexual abuse. 

Participants with both schizophrenia and substance abuse were found to have significantly higher levels of PTSD symptoms, depression, and poor impulse control. 

Those without substance abuse issues had only one higher result- they were more likely to say that "for me, the good things about medication outweigh the bad" p. 170

Additionally, those who had 10+ more days of alcohol use as well as early life trauma were found to have much higher scores of depression. 

"While it has been suggested by Brady et al (2000) that comorbidity in PTSD is the rule rather than the exception, more research is needed to fully understand the clinical implications of these various comorbid conditions" p.171

Very interestingly, some studies have indicated that "patients with schizophrenia and a history of substance abuse are less cognitively impaired and have better premorbid functioning compared to their nonsubstance abusing counterparts" p. 172
    -    This is really interesting when compared to how PTSD patients use self medication to dull the                 Thalamus and keep states of hyper-arousal at bay. I would assume that these are some of the                 same conclusions that the researchers are looking into, suggesting that the combination of                     PTSD and schizophrenia creates a much higher risk for substance abuse generally. 
 Issues with Study
    -    There is great difficulty assessing the sumpptoms of PTSD in those with psychosis because of how thought processing is experienced. 
    -    While drug tests were used to limit gross inaccuracies, there is still a chance for error when the patients you are studying are not guaranteed to comply with requests
    -    Additionally, because the study is looking at the question of cause and effect, it is a bit dubious because correlation does not always mean causation, and there could be underlying causes not thought of in the study that could be at play to affect the responses from the study
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Assessing the Role of Attention-Deficit/Hyperactivity Disorder Symptoms in Smokers With and Without Posttraumatic Stress Disorder

by John T. Mitchell, et al

Mitchell, John T., et al. “Assessing the Role of Attention-Deficit/Hyperactivity Disorder Symptoms in Smokers With and Without Posttraumatic Stress Disorder.” Nicotine & Tobacco Research, vol. 14, no. 8, Oxford University Press, 2012, pp. 986–92,
PTSD, ADHD, & Smoking

Goal of the study: 
    The goal was trying to find a commonality between ADHD, smoking and PTSD

PTSD has been shown to exacerbate the effects of ADHD, as well as possibly heightening the urge for ADHD patients to smoke. 

Those with PTSD or those with ADHD are 2-3x more likely to smoke

Underlying Risk: Dysregulated Affective Functioning
    -    Overly aggressive responses to provocation or negative stimuli
    -    Possible that both PTSD and ADHD are associated with Nicotine dependance and share affective mechanisms that are calmed by smoking. 

    -     Smokers with PTSD show more aggresive symptoms of ADHD than those without PTSD. 

    -    Smoked at least 10 cigarettes a day
    -    Patients were excluded for a number of reasons, but as far as PTSD goes, the patient must suffer from current PTSD, not Lifetime PTSD 
    -     Smoking intensity was self reported 

When reporting, it was shown that those who scored high on the 10 item brief handed out were smokers who would smoke in order to be negatively reinforced associated with relief from a negative affect: ie, patients would smoke in order to get rid of a negative symptom from their PTSD or ADHD.

    -    PTSD made ADHD symptoms stronger
    -    ADHD made PTSD patients more likely to self medicate through smoking. 

Finding suggest that PTSD and ADHD are comorbid with nicotine dependance. 


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