MODULE FIVE
ADDICTION, PTSD &
EATING DISORDERS
Introduction
In conceptualizing substance use disorders, posttraumatic stress disorders and eating
disorders, the PMHNP must understand the cross-diagnostic aspects of impulsivity and
compulsivity and relevant underlying neuroscience. Just as the PMHNP should adopt symptom-
based strategies in prescribing for all diagnoses, the psychiatric provider can apply system-
based treatment to prescribing for reward-driven disorders (i.e. substance use disorders and
process addictions). Therefore, the PMHNP must understand how drugs of abuse, food, and
behavior itself can uniquely trigger endogenous reward systems, often exceeding the “natural
high.”
All drugs, food, and/or behaviors that are involved in triggering impulsivity and compulsivity
involve an initial increase in dopamine in the mesolimbic pathway. To understand how
psychopharmacology can be used to treat substance use disorders and eating disorders, it is
important to explore the basic neuroscience behind impulsivity, compulsivity, and the reward
pathway. Impulsivity, or the prioritization of immediate reward over delayed gratification and
foresight, can result from the failure of the prefrontal cortex (“top-down control”) to adequately
suppress or regulate activity of the ventral striatum (“bottom-up”), triggered when
aforementioned mechanisms result in increased dopamine. Over time as a result of
neuroplasticity and possibly hippocampal and amygdalar cues, the pursuit of neurochemical
reward becomes habituated and virtually Pavlovian. Compulsivity, occurring regardless of
neurochemical reward and rooted in the dorsal striatum (“habit loop”) results.
Just as pleasure-conditioning in addiction can result in maladaptively conditioned behaviors,
habituated, hypervigilant stress response is the hallmark of post-traumatic stress disorders. This
stress response often involves impulsivity, and sometimes can become compulsive as well.
Triggered initially by a stressful event or circumstance, fear, panic, anxiety and hypervigilance
can also be reinforced and conditioned through external cues. While PTSD is usually
considered an anxiety / stress-related disorder and is certainly note neurologically driven by the
pleasure pathway, the hippocampus and amygdala are integral to the development of
overlapping psychopathology among substance use disorders, PTSD and eating disorders.
While first line psychopharmacological treatments for PTSD are more consistent with first-line
treatment for anxiety disorders, it is important to consider that substance use disorders and
process addictions, such as gambling and eating disorders, are often co-occurring in individuals
with a history of trauma and hypervigilance.
NOTE:
This information is to be used as a guide for safe prescribing for non-pregnant individuals ages
18-64. Prescriptive recommendations for geriatrics and pediatrics, as well as for pregnancy and
lactation, are discussed in further detail in other modules.
NEUROBIOLOGY OF ADDICTION
LEARNING OUTCOMES:
By the end of this module you will be able to:
• Define key terms central to describing and formulating relevant prescribing strategies
for substance use disorders and process addictions
• Identify mechanism of action for psychotropics used to treat substance use disorders,
specific to drug of choice (DOC)
• Describe neurological bases for the evolution of addiction, as well as of eating
disorders
• Differentiate between presentations of withdrawal, dependence, and intoxication,
choosing appropriate pharmacological and nonpharmacological strategies accordingly
• Identify protocols and triage recommendations for treating dependence in opioid abuse,
benzodiazepine abuse, and alcohol abuse respectively
• Describe pharmacological mechanism of action of medications used to treat eating
disorders
• Explain how medications and psychotherapy can be efficacious in treating PTSD,
outlining first-line recommendations in psychopharmacology
READING & RESOURCES
REQUIRED
Ch 9 & 14. In Stahl, S. M., (2013). Essential psychopharmacology : Neuroscientific basis
and practical applications (4th ed.). New York, NY: Cambridge University Press. ISBN
9781107686465
Ch 6. In Pliszka, S. R., (2016). Neuroscience for the mental health clinician (2nd ed.). New
York, NY: The Gilford Press.
SUGGESTED
National Institute on Drug Abuse: [Link]
National Institute on Alcohol Abuse and Alcoholism: [Link]
Substance Abuse and Mental Health Services Administration - Programs:
[Link]
Legislation and Guidelines for Medication Assisted Treatment (MAT):
[Link]
materials-resources/qualify-np-pa-waivers
Office-based Buprenorphine For Opioid Use Disorder:
[Link]
MEDICATION CLASSES: GROUPED BY ADDICTION CATEGORY
Alcohol Use Disorder
• Naltrexone (available in monthly injection as Vivitrol)
Opiate Use Disorder (review withdrawal protocol as well as maintenance treatment)
• Buprenorphine
• Methadone
Binge Eating Disorder
• Vyvanse
Anorexia (limited evidence)
• SSRI’s are first-line
• Prozac or Zoloft
Bulemia (limited evidence)
• SSRI’s first line
• Avoid medications that lower the seizure threshold (ex. Wellbutrin)
Additionally, review symptoms of the following from assessment class:
• Hallucinogenic intoxication
• Alcohol intoxication
• Heroin overdose
• Opiate intoxication
• Cannabis abuse and presentation
• Stimulant intoxication
With each respective substance, review symptom presentation in intoxication, as well as in
withdrawal, to treat psychopharmacologically. Review mechanism of action for medications
outlined above, and present side effects and relevant monitoring parameters and safety
considerations (as in other modules)
RESOURCES
Stahl, M. (2014). Prescriber’s guide: Stahl’s essential psychopharmacology (6th ed.). New
York, NY: Cambridge University Press: ISBN 9781107675025
Neuroscience Education Institute. (2019). NEI Prescribe (version 3.0.1) [Mobile application
software]. Retrieved from [Link]