This article is by Justin Baksh and published by Foundations Wellness Center
Substance use disorders have clear connections to certain risk factors. One-well established link – and the subject of intensive research – is the link between post-traumatic stress disorder and substance use disorder. The presence of trauma is a clear risk factor for later substance abuse, and the use of substances to self-medicate make PTSD symptoms worse, leading to a vicious cycle that is difficult to break.
What Is PTSD?
PTSD, or Post-Traumatic Stress Disorder, is a relatively common psychiatric condition that stems from witnessing or experiencing a traumatic event. According to the U.S. Department of Veteran’s Affairs, around six in 10 men and five in 10 women experience at least one trauma in their lives. Women are statistically more likely to experience sexual trauma, and men are more likely to encounter traumatic events from combat, physical assault, or other disasters.
Some people recover from experiencing trauma, while others will develop PTSD. Having PTSD is not a sign of weakness – it can happen to anyone. Some researchers believe PTSD stems from the brain failing to process trauma appropriately.
Some risk factors may make people more likely to develop PTSD. For example, those who directly experience trauma – rather than witness it – are more likely to receive a PTSD diagnosis.
How Common Is PTSD?
- Between 7 and 8% of the U.S. population will have PTSD at some point in their lives.
- In a given year in the United States, around 8 million adults will have PTSD.
- PTSD is slightly more common in women than it in in men – about 10% of women exposed to trauma in their lives will develop PTSD, compared to 4% of men.
PTSD has been a medically recognized condition since World War I, when medical staff noticed that many veterans appeared to suffer from “shell shock” or “combat fatigue,” even for years following combat. PTSD, however, does not just happen to veterans. It can occur to anyone regardless of age, nationality, ethnicity, or culture.
What Are the Symptoms of PTSD?
People who have PTSD experience intrusive, vivid thoughts and feelings related to the traumatic event… long after the exposure to trauma ended. Reliving the experience through nightmares or flashbacks, feelings of sadness, anger, fear, or detachment and estrangement from loved ones are common occurrences among individuals with PTSD. Avoiding triggers from the traumatic event, such as people or situations associated with the experience, is one way to manage the symptoms of this disorder. A person with PTSD may also experience heightened emotional reactions to triggers related to the event.
The American Psychiatric Association categorizes four main symptoms of PTSD:
- Intrusive Thoughts. Generally, intrusive thoughts involve memories, disturbing dreams, and flashbacks that interfere with everyday functioning. Intrusive thoughts can be so vivid that the person experiencing them can feel like they are going through the traumatic event again.
- Avoidance behavior. A person with PTSD may go to great lengths to avoid reliving the incident. They may avoid familiar people, events, or places than can be triggering.
- Distortions of perception. A person struggling with PTSD may have exaggerated thoughts about themselves or others (“I am evil,” or “everyone is bad”). These perceptions may contribute to ongoing feelings of shame, anger, or guilt.
- Emotional reactivity. Loved ones of a person with PTSD may describe them as irritable, short-tempered, and behaving in a way that is self-destructive. At times, this translates to knowingly participating in dangerous behavior. Cognitively, a person with PTSD may also have difficulty concentrating and trouble sleeping.
The four main categories of symptoms are generally severe enough to affect a person’s ability to function. Their quality of life will be markedly decreased. It’s important to note, however, that anyone exposed to trauma may display these symptoms for a short time after the traumatic event (a phenomenon called acute traumatic stress syndrome). The symptoms become PTSD after a person experiences the four categories of symptoms for more than a month – though many people experience symptoms over several months or even years.
Risk Factors of Untreated PTSD
Left untreated, PTSD can lead to a myriad of other problems. For example, a person who has PTSD is more likely to behave recklessly, which can lead to incidents such as operating under the influence or engaging in risky sexual behavior. Untreated PTSD can also affect the person’s loved ones, especially with regard to emotional reactivity. The immediate and extended family unit may contend with emotional outbursts, irrationality, and even the potential for violence stemming from distorted perceptions of the self or others.
Research shows that those who have untreated PTSD score significantly lower on subjective quality of life (SQOL) scales compared to those who receive intervention. Having PTSD is also a risk factor for other co-occurring disorders such as anxiety, depression, or substance use disorder.
PTSD and Substance Abuse
Research suggests that as many as 45% of people suffering from PTSD also have a substance use disorder (SUD). Considering the symptoms of PTSD, it is not difficult to see why. People with PTSD are more likely to engage in risky behavior, which may drive them toward illicit drug use. Others use drugs or alcohol as a method of self-medication. They may initially turn to alcohol and opioids to counteract the insomnia or negative feelings. Unfortunately, the body’s biological reaction to these substances actually exacerbates PTSD symptoms. This starts a cycle that can be difficult to stop without appropriate intervention.
Especially problematic is the fact that people with PTSD are more likely to experience suicide ideation, as dealing with the unresolved trauma becomes more difficult. Combined with the effects of illicit drugs such as opioids or cocaine, people with co-occurring substance use disorder and PTSD are more likely to try to commit suicide.
How PTSD Can Lead to a Substance Use Disorder
PTSD, substance use, and substance use disorders have an interconnected relationship that can affect the treatment of the individual. The high levels of stress inherent in someone suffering in PTSD makes it more likely that they will turn to alcohol or drugs either as a way to self-medicate or as a means of escape. From a practical standpoint, illicit drugs and alcohol can temporarily quell feelings of anxiety and induce a feeling or numbness or even relief. Many illicit substances work by creating higher levels of dopamine in the brain, which has a euphoric effect.
When the drug wears off, however, dopamine levels drop to increasingly low levels. Over time, as the body becomes accustomed to the substance in question, the brain stops making dopamine on its own. Essentially, this means that the affected person develops a dependence on the drug. Soon, the person with the substance use disorder takes the drug, not to experience euphoria, but to avoid the pain of withdrawal.
Common withdrawal symptoms include anxiety, sweating, tremors, insomnia, fatigue, and abdominal cramping – many of the same symptoms of PTSD. Ironically, the very reason that a person turns to substances – to quell symptoms – actually makes those symptoms worse. This creates a cycle of addiction that is difficult to stop and is often the point where the affected individual loses control over their substance use.
Over time, the chronic stress and substance use interfere with a person’s learning, memory, impulse control, and everyday ability to function. People with co-occurring SUD and PTSD may find it difficult to hold down a job or even leave the house. As mentioned, depression and anxiety disorders can also co-occur in addition to the PTSD and substance use disorder, amplifying these symptoms.
Treating PTSD and Substance Use Disorders
If a person has both PTSD and a Substance Use Disorder, it is essential to treat both conditions in order to enhance quality of life while supporting long-term sobriety. Traditionally, some treatment programs rely on the idea that treatment for PTSD should not begin until a person achieves sobriety. The underlying theory for this treatment approach is that the treatment for PTSD – which encourages individuals to face their fears – could trigger a relapse. However, the most recent research regarding PTSD and substance use disorder suggests the opposite.
The most common form of therapy for PTSD, exposure therapy, can reduce the symptoms of PTSD, even if the affected individual continues to use substances throughout the process. Recent analyses of PTSD show that exposure therapy does not make patients increase their use of substances, nor does it lead to a higher rate of dropout. These new findings encourage families to get their loved ones into treatment sooner, and to have them treated for PTSD and SUD at the same time. PTSD treatment modalities may differ slightly, but they all work to provide evidence-based techniques that address the underlying trauma and reduce the response to it, so that a person can go about their daily lives without debilitating symptoms.
Types of Dual Diagnosis Treatment Programs
Treatment programs that focus on mental health conditions and substance use disorders concurrently are called dual diagnosis, dual recovery, or co-occurring therapy programs. They offer affected individuals ways to tackle their problems simultaneously in order to maintain long-term sobriety. Treatment clinics may differ in their approach, but the end goal is the same: to improve overall quality of life, heal relationships, and restore affected individuals to their optimal level of functioning.
Cognitive Behavioral Therapy (CBT)
CBT is a nationally-recognized “gold standard” for both PTSD and substance use disorder treatment. This form of talk therapy involves patients working with a mental health provider to become self-aware of their destructive tendencies (including substance use and harmful thinking), as well as learn how to properly respond to it. CBT can also help individuals reduce anxiety and develop healthy coping skills to use whenever negative imagery occurs.
CBT is also the most effective treatment for certain populations, such as children. Trauma-Focused CBT has a robust body of evidence supporting its efficacy in the treatment of childhood trauma. A mental health professional generally talks to the child about the traumatic memory, then teaches them how to manage problematic thoughts.
One of the main benefits of TF-CBT is that it allows everyone to work through their trauma at their own place. As such, there is no set intervention time limit. Some people may require longer, more intensive sessions than others. Seeking Safety is a common trauma-focused care curriculum that can be tailored to the individual or used in group therapy settings, giving people healthy coping strategies to manage their symptoms.
Another treatment approach that simultaneously treats PTSD and substance use disorder, called COPE, is a form of exposure therapy in which the affected individual receives prolonged exposure to the event that causes triggers, while providing psychoeducation and relapse prevention strategies to address SUF. Research shows that those who complete the COPE program experience lessened PTSD symptoms and improvements in substance use habits.
A newer treatment approach, called Eye-Movement Desensitization and Reprocessing Therapy (EMDR) combines psychotherapy with eye movement exercises that help the brain process the traumatic event, thereby allowing the person to become desensitized to it. When used in combination with CBT or other psychotherapy, EMDR can effectively dampen the emotional reaction to a traumatic event, such that recalling the information does not cause a disturbance. Preliminary studies show that EMDR can help victims of trauma recover from their experiences, sometimes in as little as a few sessions.
Medications That Help Dual Diagnosis Treatment
When PTSD and substance use disorders co-occur, receiving appropriate, evidence-based treatment for both conditions is critical. Integrated therapy approaches allow the affected individual to work with qualified mental health professionals to lessen symptoms of PTSD while working toward recovery, which greatly increases the quality of life. When a substance abuse disorder is present and persistent, detox is often the first step to recovery.
PTSD can make withdrawal symptoms worse, so, in some cases, medically-assisted detox can help manage withdrawal symptoms and cravings. This allows the individual to focus on CBT and other interventions for SUD and PTSD. During medically-assisted detox, medical providers oversee the patient’s withdrawal symptoms and provide medications that ease comfort through what can be a grueling process. In some cases, such as those involving prolonged alcohol use, medically-assisted detox is necessary to avoid seizures and other life-threatening conditions.
Medication Assisted Treatment (MAT) is another avenue that can help in the integrated treatment of Substance Use Disorders and PTSD. The FDA has approved a handful of medications for the treatment of opioid use disorder and alcohol use disorder. Some, like naltrexone, come in once-monthly formulations and can be taken in the comfort of the individual’s own home. When indicated, MAT options can help reduce cravings and support a long-term recovery.
PTSD medication can also help manage troubling symptoms and improve quality of life when used in conjunction with appropriate psychotherapy. These can help manage some of the worst symptoms of the disorder, including inducing sleep and controlling anxiety or depression. Often, a combination of therapies, custom designed for each individual, are best way to provide the tools they need to develop compensatory strategies and heal.
Addressing the Underlying Issue
If a person struggling with PTSD and substance use disorder only receives treatment for the SUD, then the chances of maintaining long-term sobriety are lessened compared to those who receive dual diagnosis treatment. Without addressing the underlying reason for the substance use – the traumatic event – the person is more likely to relapse when confronted with vivid memories or other disturbing symptoms of PTSD. Concurrent, evidence-based treatment is the best way to ensure that the individual affected by PTSD and SUD has the tools to support a long-term recovery.
Recovering from co-occurring disorders like PTSD and substance use disorder requires a tailored approach and a combination of therapeutic methods. However, it’s important to understand that a person with PTSD may be reluctant to seek treatment. Since intense feelings of shame and guilt may accompany PTSD, an affected individual may be reluctant to reach out to others – even thinking that they may deserve the negative consequences of their condition. Even after entering the treatment facility, it may be difficult for them to find the motivation to address their disorders – they need the help and support of a qualified, integrated health team.
People with PTSD and co-occurring SUD require mental health experts that understand their needs. Intense psychological symptoms inherent in PTSD require specialized treatment, as well as a facility that is equipped to handle those needs. A person can only achieve recovery if they have the tools to address their substance use disorder and underlying trauma concurrently.