IRAQ WAR CLINICIAN GUIDE

Iraq War Clinician Guide
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Appendix G
146 TERENCE M. KEANEd al.
A concurrent diagnosis of substance abuse raises a number of challenging
issuesin the treatment of PTSD. Because ofthe complex interaction
that exists between these disorden, there is no clear consensus about how
to proceed in treating PTSD and wmorbid substance abuse. Because expcsure
therapy frequently results in temporarily increasedurges to use substances,
it can be argued that treabnent forPTSD shouldnot proceed until
sobriety is fmly established. It is also the case, however, that substance
use may follow directly from F'TSD symptomatologyas a means of coping
(i.e., self-medication),and a decrease in substanceuse may not occur until
the patient experiences a decrease inPTSD symptomatology.
Treabnent planning with comorbid substance abuse and PTSD re
quires consideration of multiple factors. It is critical to assess the patient's
level of motivation to stop usinglmaintaining sobriety as controversy
exists about conducting exposure therapy with individuals who are actively
using substances. It is important to understand the relationship
between substance use and FTSD symptomatology, specifically whether
substances are used to cope with PISD symptomatology and whether
PTSD symptomatology has triggered relapses for the patient. If one
chooses to begin the clinical interventions with the treatment of PTSD,
carell monitoring of any changes in alcohol and drug use is essential.
Receiving this feedback on a session-by-sessionbasis informs the clinician
of the impact of treatment on this critical comorbid problem. Initiating
treatment with abehavioral contract limiting the use of substancesduring
treatment is strongly recommended. Inaddition, patients with longstanding
substance abuse problemsmight well be encouraged tomake frequent
use of commdtyresources (e.g., AA/NA) aspart of treatmentplanning.
It may also be necessary to establisha separate provider to treat substance
abuse; this treatmentmight actually precede the F'TSD treatment and be a
condition for future work on the effects of traumatic experiences. Finally
if patients are deemed too "high risk" for exposure treahent due to
relapse risk, it is recommended that nontrauma-focused treabnents, such
as stressmanagement, anger management, and other current-focused wpingmethods,
be provided to lay the groundworkfor exposure-basedtreatment.
Panic disorder or panic attacks also occur concurrently with PTSD.
When this is the case, exposure-based treatmentsmay be augmented with
muscle relaxation and breathing retraining, two essential skills in the treatment
of panic attacks. When conducting exposure therapy with patients
who have panic attacks, it is important to prepare the patient for the
possibility that exposureexercises could lead to the occurrence of a panic
attack. Preparing them for this possibilityby instructingthem in the use of
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DEPARTMEhT OF VETERANS AFFAIRS
NATIOhAL CENTER FOR PTSD