Elsevier

Comprehensive Psychiatry

Volume 80, January 2018, Pages 132-139
Comprehensive Psychiatry

Towards a psychopathology specific to Substance Use Disorder: Should emotional responses to life events be included?

https://doi.org/10.1016/j.comppsych.2017.10.001Get rights and content

Abstract

Introduction

The severity of emotional responses to life events (PTSD spectrum) as part of Post Traumatic Stress Disorder (PTSD) in Substance Use Disorder (SUD) patients has often been considered from a unitary perspective. Light has also been shed on the possible definition of a specific psychopathology of SUD patients. This psychopathology has been proved to be independent of treatment choice, of being active in using substances, of lifetime psychiatric comorbidity and primary substance of abuse (heroin, alcohol, cocaine).

Methods

To further support this unitary perspective, in this study we have compared the severity and typology of the five psychopathological dimensions found in SUD patients, by dividing 93 HUD patients (77.4% males and 22.6% females), characterized by the lifetime absence of exposure to actual or threatened death, serious injury, or sexual violence, on the basis of the severity of their PTSD spectrum. We used the cut-off that differentiated people developing (High PTSD spectrum; H-PTSD/S) or not developing (Low PTSD spectrum; L-PTSD/S) a PTSD after the earthquake that hit L'Aquila, Italy, in April 2009.

Results

Using a canonical correlation analysis, the significant (p < 0.001) canonical variate set-one (psychopathology) is saturated negatively by “panic anxiety” and positively by the “worthlessness-being trapped” and “violence-suicide” dimensions. Set-two (PTSD spectrum) is saturated negatively by “emotional, physical and cognitive responses to loss and traumas”, and positively by “grief reactions”, “re-experiencing numbing”, “arousal symptoms” and “personality traits”. When comparing the two groups, all five psychopathological dimensions were significantly more severe in H-PTSD/S patients, who were distinguished by higher values of worthlessness-being trapped, sensitivity-psychoticism and violence-suicide symptomatology. No differences were observed regarding the typology of psychopathology.

Conclusions

This study further supports the SUD-PTSD spectrum unitary perspective and argues in favor of the inclusion of the PTSD spectrum in the psychopathology of SUD.

Introduction

Post-traumatic stress disorder (PTSD) is a severe, psychologically disruptive, often chronic condition that is triggered by traumatic life events that lead to symptoms such as persistent re-experiencing of the event, avoidance of feelings, thoughts, conversations or places associated with the trauma, adverse alterations in cognition and mood, and hyperarousal [1].

With the publication of the new DSM-5, greater attention is now being paid to the set of behavioral symptoms that may accompany PTSD; this set includes reckless or self-destructive behaviors. There is, in fact, a growing body of data dealing with the relationships between PTSD and maladaptive, risk-taking behaviors [2], [3]. In particular, previous studies have documented a strong connection between PTSD and Substance Use Disorder (SUD) [4], [5].

As the relationship between PTSD and SUD is not yet fully understood, several hypotheses have been formulated. The “self-medication” hypothesis (SMH), in which PTSD came first, was initially postulated by Khantzian [6]. It states that substances are used to relieve the painful symptoms of PTSD, and consequently subjects develop a SUD. The “high-risk” hypothesis, in which PTSD can develop from SUD, suggests that a dangerous lifestyle induced by SUD increases a subject's exposure to loss and traumatic events, and therefore raises the likelihood of PTSD [4], [7]. A causal relationship may not necessarily link PTSD and SUD, considering that a third factor could mediate PTSD/SUD comorbidity – a shared pathway or substrate – that predisposes PTSD and SUD subjects to develop these two disorders, so allowing a unified perspective (the “shared vulnerability” hypothesis).

Lastly, it could be that PTSD is best understood through a dimensional conceptualization viewed alongside the spectra of symptom severity, nature of the stressor, and responses to trauma (PTSD spectrum) [8]. This conceptualization allows us to study the PTSD spectrum-SUD relationship by adopting a unified perspective. Of course, correlations between the severity of heroin addiction and severity of the PTSD spectrum would support the self-medication hypothesis. However, in the case of primary heroin addiction, a unified perspective would be supported if correlations were demonstrated between the severity of heroin use disorder and the chronologically later severity of the PTSD spectrum. On the other hand, the severity of the PTSD spectrum that arises during addiction should be lower in the presence of a high dosage of opioid agonist medication. Agonist opioid medications are, in fact, able to limit PTSD insurgency after traumatic war events [9], [10], [11]. Any finding of high correlations between heroin addiction and PTSD spectrum will support the idea that a PTSD spectrum should be considered as an integral part of the psychopathology of the addiction, as a reaction to stress [12].

By studying life events (loss and traumatic experiences) and emotional responses to them in heroin-dependent patients before and after the age reached at the onset of dependence, we demonstrated that emotional reactivity was greater after the beginning of addiction had occurred. This increase in the intensity of emotive reactions during a drug addiction history seems to prearrange a PTSD spectrum resulting from the addictive process [13]. We had previously found positive correlations between the severity of heroin addiction, the dose of opioid medication, and the severity of the PTSD spectrum [14].

In Heroin Use Disorder (HUD) patients characterized by the lifetime absence of exposure to actual or threatened death, serious injury, or sexual violence, this PTSD spectrum, resulting from the addictive process, could display a high degree of severity. We evaluated the reactivity of the posttraumatic spectrum to loss and traumatic events included in a group of acute, catastrophic events (the 2009 L'Aquila earthquake) where the survivors experienced PTSD, and in a group of long-lasting HUD subjects who had never been exposed to catastrophic incidents. The magnitude of emotional reaction turned out to be similar in HUD subjects and in PTSD subjects who were themselves earthquake survivors. Heroin addictive behavior could have an overall effect similar to that of a single exposure to an extreme event such as an earthquake. In other words, HUD patients seem to over-react to stress [15]. Short-lasting opioids, such as heroin, are marked out by a destabilizing effect on the endogenous opioid system, determining various psychopathological consequences, including hypersensitivity to stressful stimuli (PTSD spectrum). On the other hand, long-lasting methadone does not act as a drug of abuse, but as a medication, normalizing responses to stress [16]. The use of heroin after a traumatic event remains compatible with the self-medication hypothesis, but the PTSD spectrum seems to be a standard feature of the progression of heroin addiction.

Addiction is a mental illness in which psychiatric conditions imply serious burdens. Psychopathological symptoms in Substance Use Disorder patients are usually viewed as being assignable to the context of a personality trait or comorbidity, refusing the presence of a specific psychopathology that could only be related to the addiction process. The V.P. Dole Research Group at the University of Pisa, Italy, has studied the possible definition of a specific psychopathological dimension in Substance Use Disorders. In Heroin Use Disorder subjects, using a factor analysis on all the 90 items included in the SCL-90 questionnaire, a 5-factor solution had been found. The first factor accounted for a depressive “worthlessness and being trapped” dimension; the second factor picked out a “somatic symptoms” dimension; the third identified a ‘sensitivity-psychoticism’ dimension; the fourth a ‘panic-anxiety’ dimension; and the fifth a ‘violence-suicide’ dimension [17]. These results were replicated by applying the same analysis to another Italian sample of 1195 heroin addicts entering a Therapeutic Community Treatment [18]. Further studies confirmed the clusters of symptoms, independently of demographic and clinical characteristics, active heroin use [19], lifetime psychiatric problems [20], kind of treatment received [18], and, especially, other substances used by the patient like alcohol or cocaine [21]. Moreover, these clusters were closely linked with the behavioral covariate of craving in HUD patients [22] and were able to distinguish patients affected by addiction from those affected by psychiatric diseases such as major depressive disorder [23] and obesity [24]. Studies are in progress to verify whether these dimensions can discriminate HUD patients from gamblers. In summary, our studies seem to suggest the trait- rather than the state-dependent nature of the psychopathological dimensions of SUD introduced by us.

The aim of the present study has been to further support the view that there is a psychopathology that is unique to SUD by verifying whether it is independent of the severity of emotional responses to life events, and by testing whether reactivity to life events can be included in the specific psychopathology of SUD patients. To do that we analyzed multivariate correlations between psychopathology and reactivity to life events, and we compared the quality and quantity of the five SCL-90 dimensions previously identified, by dividing HUD patients on the basis of the severity of their emotional responses to life events (whether traumatic or due to a loss). As our criterion, therefore, we used the severity that differentiated people who did develop (High PTSD spectrum) from those who did not develop (Low PTSD spectrum) a clinical post-traumatic stress disorder (PTSD) after the 2009 L'Aquila (Italy) earthquake. Our expectation was that severity, but not typology, can differentiate HUD subgroups. We can, in fact, assume that emotional responses are only a proxy for the seriousness of an illness and that a psychopathology specific to HUD is independent of the severity of that disease. Finding a significant correlation between psychopathology and the PTSD spectrum would strengthen the case for the inclusion of PTSD as an as additional factor attesting to a psychopathology that would be specific to that kind of addiction.

Section snippets

Design of the study

A naturalistic comparative cohort study was designed. Patients were evaluated on one occasion only during an Agonist Opioid Treatment (AOT) performed in three distinct locations in Tuscany, Italy. This study was carried out according to a non-interventional protocol. All patients gave their informed consent to the anonymous use of their clinical data for this independent study.

Sample

The sample consisted of 93 patients, with a diagnosis of HUD according to DSM-5 criteria. We did not use specific

Results

Forty-one (44.1%) patients showed a TALS total score of < 32 and were clustered in the L-PTSD/S group. Mean age was 41.00 ± 8.4; 37 (90.2%) were males. 52 (55.9%) subjects showed a TALS total score > 32 and fitted into the H-PTSD/S group. Out of those 52, 35 (67.3%) were males. Mean age was 40.44 ± 10.1. Males were more frequent in the L-PTSD/S group (chi = 6.89; p = 0.009). No other differences emerged from the demographic data.

Table 1 shows the results of canonical correlation analysis. Only one

Discussion

In HUD patients, psychopathology and emotional responses to life events were closely related. Patients with more severe “worthlessness-being trapped” and “violence-suicide” psychopathology showed high scores for “grief reactions”, “re-experiencing, numbing” and “arousal symptoms”. They also presented more frequent PTSD spectrum “personality traits”. Patients marked out by a high level of “panic anxiety” reported more severe “emotional, physical and cognitive responses to loss and traumas”.

Conclusions

In HUD patients who had never been exposed to actual or threatened death, serious injury, or sexual violence, the “Worthlessness-Being Trapped” and “Violence-Suicide” dimensions were closely linked with lifetime symptoms, behaviors and personal characteristics that could be manifestations springing from the development of a stress response syndrome (PTSD spectrum). On the other hand, the typology of psychopathology was independent of the magnitude of these emotional responses to traumatic and

References (50)

  • R.A. Bryant et al.

    A study of the protective function of acute morphine administration on subsequent posttraumatic stress disorder

    Biol Psychiatry

    (2009)
  • M.J. Kreek et al.

    Drug dependence: stress and dysregulation of brain reward pathways

    Drug Alcohol Depend

    (1998)
  • M.J. Kreek et al.

    Circadian rhythms and levels of beta-endorphin, ACTH, and cortisol during chronic methadone maintenance treatment in humans

    Life Sci

    (1983)
  • I. Maremmani et al.

    Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroin-addicted patients

    J Subst Abuse Treat

    (2007)
  • P.P. Pani et al.

    Buprenorphine: a controlled clinical trial in the treatment of opioid dependence

    Drug Alcohol Depend

    (2000)
  • R.C. Kessler et al.

    Posttraumatic stress disorder in the National Comorbidity Survey

    Arch Gen Psychiatry

    (1995)
  • E.B. Elbogen et al.

    Correlates of anger and hostility in Iraq and Afghanistan war veterans

    Am J Psychiatry

    (2010)
  • M. Jakupcak et al.

    Anger, hostility, and aggression among Iraq and Afghanistan War veterans reporting PTSD and subthreshold PTSD

    J Trauma Stress

    (2007)
  • E.J. Khantzian

    The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence

    Am J Psychiatry

    (1985)
  • L.K. Jacobsen et al.

    Substance use disorders in patients with posttraumatic stress disorder: a review of the literature

    Am J Psychiatry

    (2001)
  • T.L. Holbrook et al.

    Morphine use after combat injury in Iraq and post-traumatic stress disorder

    N Engl J Med

    (2010)
  • L.L. McGhee et al.

    The relationship of early pain scores and posttraumatic stress disorder in burned soldiers

    J Burn Care Res

    (2011)
  • F. Rugani et al.

    Life events (loss and traumatic) and emotional responses to them in heroin-dependent patients before and after the dependence age of onset

    Heroin Addict Relat Clin Probl

    (2011)
  • L. Dell'Osso et al.

    Life events (loss and traumatic) and emotional responses to them in acute catastrophe survivors and long-lasting heroin use disorder patients never exposed to catastrophic events

    Heroin Addict Relat Clin Probl

    (2015)
  • B. Stimmel et al.

    Neurobiology of addictive behaviors and its relationship to methadone maintenance

    Mt Sinai J Med

    (2000)
  • Cited by (0)

    View full text