Emotion Dysregulation in Comorbid Posttraumatic Stress Disorder and Substance Use Disorders: A Narrative Review

Co-occurrence of substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) is extremely common and is associated with elevated dropout and relapse rates. Given that PTSD/SUD co-occurrence rates among veterans have been found to be as high as 55?75%, it is important to identify mechanisms that may affect the interplay of both disorders. Emotion dysregulation (ED) presents a candidate mechanism that may underlie poor treatment response in co-occurring PTSD/SUD. This article proposes a transdiagnostic emotion regulation framework that considers ED conceptualized as a combination of low ability to tolerate emotional distress (low distress tolerance) and difficulties in the goal-directed use of emotion regulation strategies as a key risk factor in co-occurring PTSD/SUD. The authors review empirical findings from self-report and laboratory-based studies of ED in PTSD. They describe psychological explanations of the emotion-substance relationship and review studies documenting ED in SUDs and in co-occurring PTSD/SUD. The literature on ED in PTSD/SUD suggests that (a) patients with PTSD may resort to substances to cope with trauma-related symptoms due to ED, and (b) ED may maintain SUD symptoms and interfere with psychological treatment. Longitudinal studies on bidirectional relationships between ED and substance use in PTSD are needed, particularly research examining the course of ED in PTSD patients who use substances versus those who do not.     

Childhood Sexual Assault,Quality of Life,and Psychiatric Comorbidity in Veterans With Military and Civilian Sexual Trauma

Veterans with military sexual trauma (MST) are at risk for a variety of psychiatric conditions, including posttraumatic stress disorder (PTSD) and depression. Survivors of MST are also likely to experience diminished quality of life (QoL). Individuals with higher lifetime incidence of sexual trauma may also be at increased risk for poorer outcomes in QoL and psychiatric symptomatology. The differences in psychological sequelae among those who have experienced sexual trauma as children, and those whose sexual trauma exposure is limited to adulthood are relatively understudied. The majority of sexual trauma literature has focused primarily on civilian trauma, and comparatively few studies have specifically examined psychosocial sequelae (e.g., QoL) in veterans with MST. This study examined how childhood sexual abuse (CSA) affects overall QoL as well as severity of PTSD and depressive symptoms. Veterans who reported CSA had significantly greater depression symptom severity than veterans who did not. No significant differences in PTSD symptom severity or QoL were found between veterans who did and did not report CSA. Results highlight the need for further examination of the relationship between CSA and depression in veterans with MST-related PTSD who also report CSA.     

Examination of the Relationship Between PTSD and Distress Tolerance in a Sample of Male Veterans With Comorbid Substance Use Disorders

Distress tolerance (DT), the perceived or actual ability to tolerate negative emotional or physical states, is inversely related to posttraumatic stress disorder (PTSD) symptoms in civilian, community samples. No studies to date have examined the relationship between DT and PTSD in clinical samples of veterans with a comorbid diagnosis of PTSD and a substance use disorder (SUD). Thus, the present study examined the relationship between DT and PTSD in a sample of predominately African American, male veterans (n = 75) diagnosed with comorbid PTSD and SUD (according to a structured clinical interview). Results of hierarchical linear regression models indicated that DT was inversely related to total PTSD symptom severity score, above and beyond depressive symptoms and SUD severity. Of the 4 symptom clusters, DT was inversely associated with intrusions and hyperarousal. These findings are discussed in light of previous work with civilian samples. Determining whether treatment incorporating DT skills would be useful for veterans undergoing PTSD treatment should be evaluated.     

Short‐term cognitive‐behavioral treatment in multicultural primary care of patients with longstanding backache

The efficacy of cognitive‐behavioral therapy in multi‐cultural primary care patients with longstanding backache is not evaluated. The purpose of this study was to investigate the outcome of a four weekly‐treatment given by primary care physicians regarding pain‐related worry, depression and severe pain and to determine which social, clinical or gender factors were associated with outcome.The study group consisted of 245 patients in consecutive order from 19 countries, 18 to 45 years, entering rehabilitation program because of longstanding backache. Prevalences of pain‐related worry and depression and severe pain was counted and compared before and after. Logistic regression was used to calculate the odds (OR; 95% CI) for persistent pain‐related worry and/or persistent depression and severe pain (VAS ≥ 50). The prevalences of pain‐related worry and depression were both significantly lower after treatment (pain‐related worry 83% before vs. 38% after; depression 43% before vs. 31% after). Also the number of patients scoring ≥ 50 VAS was a little, but significantly, fewer (68% vs. 61%). Use of interpreter doubled the risk of having persistent pain‐related worry (OR 2.1; 95% CI 1.1–4.1) but the risk was not significant regarding persistent depression (OR 1.8; 0.6‐5.4). The rating of VAS rating ≥ 50 after treatment was twice as high, OR 2.3 (95% CI 1.1–4.6) in the 38–45 year old age group. To conclude, a focus on pain ideas reduced pain‐related worry and depression in these patients with various sociocultural backgrounds and longstanding backache.     

Psychometric properties of the Norwegian version of the Childhood Trauma Questionnaire in high‐risk groups

The Childhood Trauma Questionnaire ‐ Short Form (CTQ‐SF) is widely used to measure childhood abuse of all types. In the present study, we examined the psychometric properties of the Norwegian version of the instrument. The participants constituted four subsamples (n = 517): substance abusers (n = 126), psychiatric patients (n = 210), prisoners (n = 109) and adolescents in out‐of‐home placements (n = 72). Confirmatory factor analysis revealed a reasonable fit of the data to the original five‐factor structure of the CTQ‐SF. Measurement invariance was found across gender and the four subsamples. It was concluded that the Norwegian version of the CTQ‐SF has acceptable psychometric properties, with good reliability and satisfactory accuracy, to assess different dimensions of childhood trauma.     

‘I don't want to be the mother of a paedophile’: the perspectives of mothers whose adolescent sons with learning disabilities sexually offend

The subject of sexual abuse is a major focus of professional and public concern. Sexual abuse of (and by) people with learning disabilities evokes even greater disquieting emotions, and makes severe demands on the social services, and the criminal justice system. The aims of the project were: 1) to determine whether group psychotherapy produced effective outcomes for adolescent boys with learning disabilities who exhibit sexually abusive behaviour, 2) to explore the perspectives of parents and other care-givers, and 3) to document the nature and extent of service support to families. This paper focuses solely on the mothers' perspectives. This was a three-year project with six boys (under 16) receiving group psychotherapy, using both quantitative and qualitative methods. Clinical measures were used to track changes throughout the course of psychotherapy. Semi-structured interviews (taped and transcribed) were held (separately) with the boys, their parents, paid care-givers and the therapists. The mothers tried hard to make sense of, and come to terms with, what was happening to their sons and to themselves, they struggled to reconcile their own confused and often conflicting emotions, and to maintain their own sense of identity. They felt almost totally unsupported by the services, both in the past and present, and could see little hope for the future. There is an urgent need for development of effective and sympathetic services for the parents of boys with learning disabilities who have been abused, and who are now showing abusive behaviour.     

Factors of Empowerment for Women in Recovery from Substance Use

Empowerment is an interdisciplinary construct heavily grounded in the theories of community psychology. Although empowerment has a strong theoretical foundation, few context-specific quantitative measures have been designed to evaluate empowerment for specific populations. The present study explored the factor structure of a modified empowerment scale with a cross-sectional sample of 296 women in recovery from substance use who lived in recovery homes located throughout the United States. Results from an exploratory factor analysis identified three factors of psychological empowerment which were closely related to previous conceptualizations of psychological empowerment: self-perception, resource knowledge and participation. Further analyses demonstrated a hierarchical relationship among the three factors, with resource knowledge predicting participation when controlling for self-perception. Finally, a correlational analysis demonstrated the initial construct validity of each factor, as each factor of empowerment was significantly and positively related to self-esteem. Implications for the application of psychological empowerment theory and research are discussed.     

Thoughts about the development of a potential space in the psychotherapeutic treatment of infantile psychosis

This paper describes the usefulness for the child psychotherapist of some Winnicottian concepts in psychoanalytic treatment of very young psychotic children. Particular attention is given to the concept of ‘potential space’ as Winnicott has formulated it in his writings. Three clinical cases are presented, one of these includes a complete mother-child session in order to show how the therapist can work to create a space where psychic events can become possible.     

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This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.