PS531 Unit 3 PTSD and Alcohol Case Study Example

Six Beers to Sleep Through the Dream: A PS531 Unit 3 Case Study of an Army Veteran With PTSD and Alcohol Use Disorder at a Paper Mill Town Agency

[Student Name]

Purdue University Global

PS531: Co-Occurring Disorders and Treatments

Unit 3 Trauma and Substance Use Case Study

[Instructor Name]

[Date]

The client, his family, the agency and every detail of the case are composite and illustrative; the sources cited are real.

Identifying Information and Referral

Ron is 46, married, with two teenage sons, and has run a paper machine at the mill in Escanaba for fourteen years, mostly on rotating night shifts. He served two tours in Iraq with the Army. In 2006, a roadside bomb hit the truck ahead of his in a convoy, killing two soldiers he knew. His wife insisted he seek help after he punched a hole in the bedroom wall during a nightmare and, the next morning, could not remember doing it. He came to our agency rather than the VA clinic in Iron Mountain because the drive is shorter and he did not want to "sit in a waiting room full of guys like me." With his consent, we will still coordinate with the VA, which can offer services our agency cannot, such as disability evaluation and specialty sleep care.

History

Ron began drinking heavily after his second tour. Over the past five years, he has settled into a pattern of six to eight beers each night after his shift, more on his days off. He says the beer is the only thing that lets him sleep without "the dream," in which he is back on the road and the truck ahead explodes. He avoids fireworks, the smell of diesel exhaust at the mill's loading dock bothers him and at the diner on Ludington Street he always takes the corner booth facing the door. He has tried to cut back twice and lasted three nights each time, sleeping two hours a night and waking from nightmares soaked in sweat.

Diagnoses

Every cluster of the PTSD diagnosis shows up in Ron's life. The convoy returns in dreams and daytime flashes, he steers clear of diesel smell and fireworks, he carries heavy guilt about the two soldiers and believes he should have seen the bomb, and he startles at slammed doors and snaps at his sons. His drinking is a severe alcohol use disorder: the six beers he plans often become eight, two attempts to cut back each collapsed after three nights, he needs far more than he once did to sleep, quitting brings two-hour nights and drenching dreams and he kept drinking after his wife's tears and the hole in the wall.

How the Two Disorders Feed Each Other

Khantzian (1997) proposed that people turn to substances that relieve their particular suffering. Ron's beer does exactly that, at least in the short term: it blunts the arousal that keeps him awake and seems to keep the nightmare away. But alcohol fragments sleep later in the night, worsens irritability and mood over time and prevents him from learning that the memory can be faced. When he stops, withdrawal brings back insomnia and the nightmares return stronger, which confirms his belief that he needs the beer.

Each beer buys Ron a few hours without the dream and then charges interest the next time he tries to stop.

Integrated or Sequential?

The traditional approach would treat the drinking first and the PTSD only after months of sobriety, out of concern that trauma-focused therapy might trigger relapse. SAMHSA's protocol now recommends integrated care, treating co-occurring disorders at the same time by the same team when possible (Substance Abuse and Mental Health Services Administration, 2020).

Mills et al. (2012) tested that concern directly. They randomly assigned 103 adults with PTSD and substance dependence in Sydney to usual substance use treatment or usual treatment plus COPE, an integrated program of thirteen ninety-minute sessions combining prolonged exposure with relapse prevention. Both groups improved, but the COPE group showed significantly greater reductions in PTSD symptoms at nine months. Substance dependence improved in both groups to a similar degree, and exposure therapy did not increase substance use or worsen outcomes.

The finding answers the main fear behind sequential treatment. For Ron, waiting to treat PTSD until he is sober might mean waiting indefinitely, since the nightmares are what drive the drinking.

Treatment Plan

The first step is safe withdrawal. Because Ron's past attempts brought severe insomnia and his drinking is heavy, our agency's physician will assess his withdrawal risk and supervise a short outpatient taper, and will consider medication for nightmares and for alcohol use, such as naltrexone.

The second step is integrated therapy modeled on COPE, delivered by our team's trauma-trained psychologist. Sessions will combine coping skills for craving and high-risk situations with prolonged exposure: Ron will gradually retell the convoy memory in session and approach avoided reminders, such as the loading dock, in a planned way. Early sessions will build skills and stabilize sleep before exposure begins.

The third step addresses shift work. Rotating nights disrupt sleep for anyone. With Ron's consent, I will help him request a fixed day shift for six months through the mill's accommodation process.

The fourth step involves his wife. She will join two sessions to learn about PTSD and the treatment, and to plan what she will do if a nightmare turns violent, including sleeping in another room for now.

Safety

Ron's guilt about the soldiers who died and his drinking raise suicide risk. I asked directly; he denied thoughts of suicide but has a hunting rifle at home, and veterans with PTSD and heavy drinking carry a higher risk than either problem alone would suggest. With his agreement, the rifle and ammunition are stored at his brother's house during the early months of treatment, and he has the Veterans Crisis Line number in his phone.

Goals

Within two weeks, Ron completes withdrawal safely and begins coping skills sessions. Within three months, his PTSD checklist score drops by at least ten points and he drinks no more than two nights a week, moving toward abstinence. Within six months, he completes exposure therapy and reports sleeping at least five hours most nights without alcohol.

Limits

The COPE trial was conducted in Australia with participants dependent on various substances, not only alcohol, and many dropped out. Ron's response may differ, and the plan will be adjusted if exposure proves too distressing.

Conclusion

Ron's PTSD and alcohol use disorder are one problem with two names: he drinks to escape the dream, and the drinking keeps the dream alive. Khantzian's self-medication hypothesis explains the cycle, SAMHSA's protocol supports integrated care and Mills and colleagues' trial shows that treating PTSD with exposure therapy during substance treatment can reduce PTSD without worsening drinking.

References

Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231-244. https://doi.org/10.3109/10673229709030550

Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., Sannibale, C., Barrett, E. L., Merz, S., Rosenfeld, J., & Ewer, P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA, 308(7), 690-699. https://doi.org/10.1001/jama.2012.9071

Substance Abuse and Mental Health Services Administration. (2020). Substance use disorder treatment for persons with co-occurring disorders (Treatment Improvement Protocol Series, No. 42; SAMHSA Publication No. PEP20-02-01-004).