Co-Occurring Disorder Analysis
Post Traumatic Stress Disorder and Alcohol Abuse
Mental health disorders are sometimes accompanied by other disorders, which can have major implications for treatment planning, and symptom presentation in the patient and may also affect patient outcomes. To understand what it means to have a co-occurring disorder, several definitions of comorbidity have been offered, but a simple one is that when there exists more than one disorder in the individual, there are said to be co-occurring disorders (Valderas et al., 2009). This paper will explore two specific co-occurring disorders, namely Posttraumatic Stress Diagnosis and a co-occurring Major Depressive Disorder. It will discuss what that comorbidity may look like, the relationship between both disorders, as well as how the co-occurring disorders can impact the individual.
In an article published in the Annals of family medicine, comorbidity is defined as the existence of more than one separate disorder in a person (Valderas et al., 2009). The article looks at four key types of distinctions with regard to co-occurring disorders. The first is the nature of the health condition; the second is the relative significance of the co-occurring conditions; the third is the chronology of the presentation of the conditions; and finally, some extended conceptualizations of the disorders (Valderas et al., 2009). The latter construct explores the impact of the disorders on patient outcomes and physiology and points to other patient complexities.
Posttraumatic Stress Disorder (PTSD)
According to the DSM 5 (APA, 2013), Posttraumatic stress disorder (PTSD) is a psychological disorder that may occur in persons who have witnessed or experienced a traumatic incident, such as a natural disaster, a serious accident, a terrorist attack, war/combat, or rape, or who are threatened with death, sexual assault, or serious injury. People with PTSD have intense, disturbing thoughts and feelings that last beyond the occurrence of the traumatic event related to their experience. Individuals may relive the event via flashbacks or dreams; they may feel sorrow, anxiety, or anger, and they may feel disconnected or estranged from other people. People with PTSD may avoid conditions or individuals that remind them of the traumatic incident, and they may have strong adverse reactions to anything as common as loud noise or accidental contact (APA, 2013). In essence, exposure to a disturbing traumatic event is needed for a PTSD diagnosis. The exposure may, however, be indirect rather than first-hand. PTSD, for instance, could occur in any person learning about a near family or friend’s violent death. PTSD may also happen as a result of prolonged exposure to horrific trauma information, such as first responders subjected to witnessing incidents of violent trauma.
Major Depressive Disorder (MDD)
Depression (major depressive disorder) is a common and serious medical illness that negatively affects how someone feels, thinks, and acts (APA, 2013). Depression causes feelings of sadness and a loss of interest in activities. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home. Depression symptoms can vary from mild to severe and can include: feeling sad or having a depressed mood; loss of interest or pleasure in activities that were once enjoyed; changes in appetite — weight loss or gain unrelated to dieting; trouble sleeping or sleeping too much; loss of energy or increased fatigue; feeling worthless or guilty; difficulty thinking, concentrating or making decisions; and thoughts of death or suicide (APA, 2013).
PTSD and MDD Comorbidity
The DSM 5 states that individuals with PTSD are 80% more likely to have symptoms that meet diagnostic criteria for at least one other mental disorder (APA, 2013) than those without PTSD. Validating that point is extensive documentation of the comorbid disorders present in individuals with PTSD, such as depression, bipolar, anxiety, substance abuse, or obsessive-compulsive disorders (Kessler et al., 1995). Multi-morbidity is the presence of multiple diseases in one individual, as has been seen in Veterans returning from combat, who have been diagnosed with cases of PTSD, a traumatic brain injury (TBI), and Major Depressive Disorder (MDD) simultaneously (Kessler et al., 2011). In the same way, there exist comorbidities or multi-morbidities in persons with PTSD, conduct disorder, and substance use disorder, seen most prevalently among males than among females (Kessler et al., 1995).
Comorbidity and Mutli-morbidity Issues
Chronology
Time Span and Sequence
The relevant factors for comorbid diseases are time period and sequence. The first element relates to the time period over which the co-occurrence of 2 or more conditions is measured. The series in which comorbidities arise is a distinct but related question that may have significant consequences for the genesis, prognosis, and treatment of the disorders (Valderas et al., 2009). Patients with established PTSD, for example, who receive a new diagnosis of major depression may be very different from patients with major depression who are later have been diagnosed with PTSD, although from a cross-sectional perspective, both may be viewed as patients with PTSD and depression.
Causal
Some studies have attempted to investigate a causal correlation between PTSD and depression in combat Veterans, but no study has been able to provide evidence of a causal relationship (Tanielian et al., 2008). Some research indicates that preexisting SUD is linked to increased chances of subsequent PTSD and/or traumatic event exposure, but results are contradictory. For instance, people with a preexisting alcohol use disorder or SUD met PTSD requirements at higher rates after the bombing of Oklahoma City than those without previous SUD requirements (Berenz & Coffey, 2012).
Characteristic
MDD and PTSD have similar characteristics, so it is important that once an individual has met the criteria for both disorders, clinicians understand that the disorders influence one another. Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment (Campbell et al., 2007). Approximately half of the people seeking SUD treatment meet current PTSD criteria, and compared to those without such comorbidity, people with co-occurring PTSD-SUD tend to have poorer treatment outcomes (Berenz & Coffey, 2012).
Patient Complexity
A newly emerging construct of patient complexity recognizes that the burden of morbidity is influenced not only by health-related characteristics, but also by characteristics of socio-economic, cultural, environmental, and patient behavior. From a clinical perspective, it is apparent that disease factors interact with social and economic factors, which can make clinical management of the disorders more time-consuming and resource-intensive. Any of these factors can also exacerbate an already preexisting disposition to substance abuse disorder or increase the risk of a substance abuse diagnosis (Kessler et al., 2011; Berenz & Coffey, 2012). Additional suicide risk factors among MDD-PTSD+ patients that were cited by others were lower social support and higher disability prevalence (Campbell et al., 2008).
Conclusion
Mental health conditions are often compounded by other conditions that may have important consequences for treatment course and preparation, the patient’s presentation of symptoms, and may also impact patient outcomes. A brief definition of comorbidity has been given to explain what it means to have a co-occurring disorder. Two particular co-occurring conditions, Posttraumatic Stress Disorder, and a co-occurring Major Depressive Disorder, were discussed in this paper in conjunction with a multi-morbidity of substance abuse disorder. It addressed what comorbidity and multi-morbidity can look like. The relationship of influence of the disorders was described, as well as how the person may be affected by the co-occurring disorders.
References
American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, 5th ed.; American Psychiatric Association: Washington, DC, USA, 2013.
Berenz, E. C., & Coffey, S. F. (2012). Treatment of co-occurring posttraumatic stress disorder and substance use disorders. Current psychiatry reports, 14(5), 469–477. https://doi.org/10.1007/s11920-012-0300-0
Campbell, D. G., Felker, B. L., Liu, C. F., Yano, E. M., Kirchner, J. E., Chan, D., Rubenstein, L. V., & Chaney, E. F. (2007). Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. Journal of general internal medicine, 22(6), 711–718. https://doi.org/10.1007/s11606-006-0101-4
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of general psychiatry, 52(12), 1048–1060. https://doi.org/10.1001/archpsyc.1995.03950240066012
Kessler, R. C., Lane, M. C., Shahly, V., & Stang, P. E. (2011). Accounting for comorbidity in assessing the burden of epilepsy among US adults: Results from the National Comorbidity Survey Replication (NCS-R). Molecular Psychiatry, 17(7), 748-758. doi:10.1038/mp.2011.56
Tanielian, T., Jaycox, L. H., Adamson, D. M., Burnam, M. A., Burns, R. M., Caldarone, L. B., Cox, R. A., D’Amico, E. J., Diaz, C., Eibner, C., Fisher, G., Helmus, T. C., Karney, B., Kilmer, B., Marshall, G. N., Martin, L. T., Meredith, L. S., Metscher, K. N., Osilla, K. C., … Yochelson, M. R. (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. https://www.rand.org/pubs/monographs/MG720.html
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Question 
Explain the characteristics and complexities associated with the assessment and treatment of co-occurring disorders. Describe challenges associated with the case of Elena.
Co-Occurring Disorder Analysis
If you were creating a 30-day treatment plan for Elena, identify two short-term goals based on the challenges that Elena is facing. Include an action step that you would include in her treatment plan.
Post your completed Treatment Plan.
Elena is a 44-year-old hearing-impaired Latina female who was admitted to the inpatient treatment facility for alcohol dependence, where you are a counselor working with people with addictions. During her admission, Elena expressed reluctance to undergo treatment, stating that her family did not approve of counseling or psychiatric services because they saw it as a sign of weakness. During her admission, she began crying and had difficulty stopping. She stated that her husband had left her and that her two teenage children were home alone. Elena was inebriated, under emotional distress, and ended up being carried to her assigned room by two staff members.
Your psychosocial intake assessment revealed Elena is also manifesting signs and symptoms of a major depressive disorder. You know that Elena needs help with her alcohol addiction, but you also know that her depression might be a cause or an effect of alcoholism.
Addressing the needs of diverse populations and co-occurring disorders can be a challenging aspect of addiction counseling. This week, you evaluate strategies for addressing the complexities of co-occurring disorders, also known as comorbid disorders, and you create a 30-day addiction treatment plan for Elena, as presented in the case study above.