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What we know

Trauma-focused treatments are effective in reducing overall symptoms of PTSD. Previous studies have shown that some symptoms remain after treatment, even in people who don’t have a diagnosis of PTSD any longer. However, no studies have examined residual symptoms of PTSD in those with a co-morbid alcohol use disorder (AUD) diagnosis. It is also unknown which AUD symptoms may persist in people after integrated treatment for PTSD/AUD. 

What we wanted to know

Clinicians often wonder whether even if their patients do well in treatment, will some symptoms of PTSD or AUD remain? Additionally, even if symptoms get better overall, what individual symptoms may persist and how should they be addressed? We set out to understand whether there are differences in the likelihood of individual symptoms of PTSD or AUD persisting between two types of integrated psychotherapy for PTSD/AUD. We also tested whether there were differences in the likelihood of symptoms remaining in those who had a diagnosis of PTSD at the end of treatment versus those who no longer had a diagnosis.

Previous studies have shown that insomnia, irritability/anger, hyperarousal, detachment from others, and distress related to trauma reminders are common residual symptoms after PTSD treatment. One study that compared Prolonged Exposure (PE) therapy to a non-trauma focused treatment called Present Centered Therapy (PCT) in female survivors of sexual assault showed that those who did PE had a lower chance than those in PCT of having persistent symptoms of intrusive memories, avoidance of people/places, detachment/estrangement from others, and restricted range of affect (Schnurr & Lunney, 2019). 

Using data from a randomized controlled trial (Norman et al., 2019) that compared an integrated PTSD+substance use disorder trauma-focused treatment (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure; COPE) with an integrated present centered therapy that does not include exposure (Seeking Safety), we examined if there were differences between treatments in residual symptoms of PTSD/AUD. Although previous studies have examined this question in those with PTSD only, this was the first to look at co-morbid PTSD/AUD.

What we learned

We found five symptoms that were more likely to persist in participants who were randomized to Seeking Safety than to COPE: avoidance of people/places, inability to experience positive emotions, hypervigilance, difficulty concentrating, and difficulty sleeping. There were no differences in which AUD symptoms were likely to persist. This shows that trauma-focused treatment is more effective at reducing certain symptoms of PTSD, but that both treatments are comparably effective in reducing AUD symptoms. 

We also found that in those who no longer had PTSD after treatment, about a third still had symptoms of exaggerated startle and irritability/aggression. This shows that even though trauma-focused treatments are useful in reducing overall PTSD symptoms, additional interventions such as cognitive-behavioral therapy for insomnia may help those with persisting symptoms. In those who no longer had an AUD diagnosis at posttreatment, withdrawal (34.8%), unsuccessful quit attempts (11.1%), and using in larger amounts (4.0%) were most likely to persist. It is possible that these residual symptoms may be caused by the long-term nature of AUD rather than individuals not responding well to treatment. 

What’s next 

This study helped us to understand more about what symptoms of PTSD and AUD may persist at the end of integrated treatment. Our study adds support to the idea that exposure-based trauma-focused treatments are effective in reducing individual PTSD symptoms (Schnurr & Lunney, 2019). There are still many more questions to answer. Why were hyperarousal symptoms more likely to persist in our comorbid PTSD/AUD sample but not in the PTSD-only sample? Would modifying COPE and Seeking Safety to target hyperarousal symptoms in additional ways further reduce these symptoms by the end of treatment? 


Norman, S.B., Trim, R., Haller, M., Davis, B.C., Myers, U.S., Colvonen, P.J., Blanes, E., Lyons, R., Siegel, E.Y., & Angkaw, A.C. (2019). Comparing integrated exposure therapy and integrated coping skills therapy for comorbid PTSD and alcohol use disorder: A randomized controlled trail. JAMA Psychiatry, 76 (8), 791-799. doi:10.1001/jamapsychiatry.2019.0638.

Reference Article

Tripp, J. C., Angkaw, A., Schnurr, P., Trim, R. S., Haller, M., Davis, B. C., & Norman, S. B. (2020). Residual symptoms following exposure versus seeking safety for veterans with co-occurring PTSD and alcohol use disorder. Journal of Traumatic Stress. doi.org/10.1002/jts.22552

Questions for Discussion

  1. Why are symptoms of hyperarousal the most common PTSD symptoms to persist in individuals without a PTSD diagnosis at the end of treatment? 
  2. How can we modify existing treatments like COPE and SS to reduce the likelihood of particularly symptoms (e.g. exaggerated startle, irritability/aggression) persisting? 

About the Authors

Jessica C. Tripp, Ph.D., is a postdoctoral fellow in the Interprofessional Advanced Fellowship in Addiction Treatment at the VA San Diego Healthcare System and University of California San Diego School of Medicine.  
Sonya B. Norman, Ph.D., is Director of the PTSD Consultation Program for the National Center for PTSD and a Professor in the Psychiatry Department in the University of California San Diego School of Medicine.