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Post-traumatic stress disorder (PTSD) is a mental health disorder that develops in connection with exposure to a traumatic environment or event.1 It is common for those who have PTSD to also have a comorbid alcohol or drug addiction, a situation referred to as a dual diagnosis.1 Substance abuse issues co-occur in the context of PTSD for a variety of reasons, and may develop as a means of self-medication of unpleasant or distressing symptoms. Attempts at self-medicating can be counterproductive, as drug and alcohol abuse often exacerbates certain symptoms of PTSD and can severely complicate the recovery process. Fortunately, there are dual diagnosis treatment programs available that provide comprehensive care and specialize in addressing the unique problems associated with PTSD and substance abuse.

What Is PTSD?

Veteran sitting on bench with head down suffering from PTSDPTSD is a mental health condition that develops in some individuals after exposure to severe injury, sexual violence, or death (either threatened or actual). The trauma could include witnessing the event, experiencing it directly, finding out that a traumatic event has occurred to a loved one, or being subjected to explicit details surrounding the trauma.2  People repeatedly exposed to trying situations, such as veterans and first responders, are more vulnerable to developing PTSD. Other populations at risk include victims of gang, domestic, or sexual violence and survivors of natural disasters.

PTSD causes significant impairment, often disrupting a person’s ability to function in many areas of life, including their career, social relationships, and education. There are many different symptoms of PTSD that a person may present with. Symptoms typically emerge within the first 3 months following the traumatic event, but some symptoms won’t appear for months or even years after.2

There are four characteristic categories of symptoms that are specific to PTSD. These categories are:1,2

  1. Intrusion.
  2. Avoidance.
  3. Mood and cognition.
  4. Arousal and reactivity.

In order for someone to meet the criteria for PTSD, they must exhibit 1 or more intrusive symptoms, 1 or both avoidant symptoms, 2 or more mood and cognitive symptoms, and 2 or more arousal and reactivity symptoms, and these symptoms must be present for more than 1 month.2

Potential intrusive symptoms include:2

  • Repeated disturbing memories associated with the event.
  • Repeated frightening or upsetting dreams related to the event.
  • Repeated flashbacks in which the person re-experiences the event.
  • Severe and intense mental distress in response to exposure to external or internal triggers related to the event.
  • Physiological reactions to external or internal triggers that mimic or symbolize a detail of the event.

Possible avoidant symptoms include:2

  • Avoidance of upsetting or terrifying feelings, thoughts, or memories related to the traumatic event.
  • Avoidance of external cues (conversations, objects, activities, places, people) that cause distressing feelings, thoughts, or memories.

Negative changes associated with mood and cognition may include:2

  • Inability to recall a vital aspect of the event, often due to dissociative amnesia.
  • Consistent negative beliefs about the world, others, or oneself.
  • Consistent, distorted thoughts about the reason for or ramifications of the event that resulted in self-blame.
  • Consistent negative emotions, such as shame, guilt, anger, or fear.
  • Reduced interest or participation in important activities.
  • Feelings of alienation or detachment from other people.
  • Consistent inability to feel positive emotions, such as love, satisfaction, or joy.

Noticeable changes associated with arousal and reactivity can include:2

  • Anger or irritability, often characterized by physical or verbal aggression towards objects or people.
  • Self-destructive or impulsive behavior.
  • Hypervigilance, or an intensified sensitivity to external activity, which can result in increased anxiety.
  • Exaggerated response to startling stimuli.
  • Difficulty focusing on tasks.
  • Sleep disturbances, such as restless sleep or problems falling or staying asleep.

One of the most distressing risks associated with PTSD is that of suicide.To diagnose PTSD, the symptoms must cause significant disturbances in occupational, social, relational, and other important areas of life. One of the most distressing risks associated with PTSD is that of suicide. It is common for people with PTSD to both have suicidal thoughts and make attempts at suicide, as traumatic events increase an individual’s suicide risk.2

Other potential consequences of PTSD include increased absences from work, reduced income, reduced occupational and educational success, and poor family and social relationships.2

Comorbid Substance Abuse

The abuse of psychoactive substances can worsen the symptoms of PTSD and other psychiatric disorders, as well as have detrimental effects on a person’s physical health. These hazards can interfere with the recovery process and without thorough and individualized treatment, continued drug or alcohol abuse can have dire consequences, such as overdose, coma, or death.

People who are diagnosed with PTSD are 80% more likely to have a co-occurring mental health condition, such as a substance use disorder.The prevalence of co-occurring PTSD and substance addiction is alarmingly high. In fact, people who are diagnosed with PTSD are 80% more likely than those without the disorder to also have a co-occurring mental health condition, such as a substance use disorder, depression, or anxiety.2

Below are additional statistics retrieved from national epidemiologic studies:3

  • 46.4% of people with PTSD met the diagnostic criteria for an addiction to alcohol or drugs.
  • Nearly 52% of men with PTSD had a substance addiction.
  • Men with PTSD are at least twice as likely than men without PTSD to struggle with substance abuse or dependence.
  • Nearly 28% of women had comorbid PTSD and drug or alcohol addiction.
  • Women diagnosed with PTSD are more than twice as likely than women without the disorder to meet criteria for alcohol abuse or dependence and 4 times as likely to meet criteria for drug abuse or dependence.

To shed light on the high rate of substance abuse amongst those with PTSD, it’s important to understand how trauma and stress can impact the brain. Typically, when a person experiences stress, the brain releases hormones that send messages throughout the body that promote survival, manage fear-related actions, and increase alertness. Once the threat is no longer present, the brain and body normalize the levels of these signaling hormones, at which point a person is no longer in a state of arousal.4

In some who experience trauma, this stress-response no longer functions properly. Traumatic events such as abuse, combat, or rape can cause lasting changes in the parts of the brain that regulate stress. These changes in brain function and structure are theorized to be responsible for many of the symptoms of PTSD, such as nightmares, sleep problems, hyperarousal, flashbacks, intrusive thoughts, and memory and concentration impairments.4Woman suffering from PTSD and substance abuse

Because of these significant and severe problems associated with PTSD, many individuals in this population use alcohol or drugs to cope. Not every victim of trauma abuses substances for the same reason. Below is a list of possible reasons why someone with PTSD may abuse drugs or alcohol:5,6

  • To forget about terrible memories associated with the trauma
  • To fall asleep if insomnia or recurring nightmares are experienced
  • To distract from personal problems
  • To reduce or self-medicate mood symptoms

Even though drugs or alcohol may be used to attempt to manage these PTSD symptoms, the use of substances can actually exacerbate these problems and lead to further impairment in an individual’s life.

Although any type of mind-altering substance may be abused by victims of trauma, there are several substances that are more commonly abused by this population than others. They include:2,6,7

  • Alcohol.
  • Marijuana.
  • Heroin.
  • Cocaine.

Who Is Affected?

An estimated 8% of the general population meets the diagnostic criteria for PTSD, and women are more likely than men to have this condition.1 Although anyone who experiences trauma is at risk for developing PTSD, there are certain populations that are more vulnerable to this mental health disorder, such as:2,6

  • Veterans.
  • Police officers.
  • Firefighters.
  • Emergency medical personnel.
  • Victims of gang or domestic violence.
  • Survivors of natural disasters.
  • Survivors of rape.
  • Survivors of politically or ethnically motivated imprisonment or genocide.

Woman affected by PTSD sitting on ground with hand on headIn the case of soldiers, firefighters, police officers, and emergency medical personnel, these professions increase the risk of exposure to traumatic situations or events, which is why the rate of PTSD is higher. According to the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5), anywhere from 33% to 50% of those exposed to military captivity and combat, rape, or confinement and genocide develop PTSD.2 There are higher rates of PTSD in African Americans, American Indians, and U.S. Latinos, compared to Asian Americans and U.S. non-Latino whites.2

Recent research suggests that up to 50% of veterans with PTSD also have a comorbid alcohol or drug addiction.8 Furthermore, about 50% of people seeking substance abuse treatment also have PTSD, a figure which is more than 5 times that of the United States prevalence rate.9

What is a Dual Diagnosis?

Dual diagnosis is the term used to refer to the presence of a substance addiction and a co-occurring mental health disorder, such as PTSD. Having comorbid disorders can complicate recovery due to the fact that these two conditions can fuel and magnify the severity of each other.

For instance, someone who is addicted to drugs or alcohol may use these substances to self-medicate the symptoms of PTSD. If they quit using substances of abuse, the symptoms they were attempting to treat may intensify. This re-emergence of symptoms, combined with withdrawal symptoms, can make it extremely challenging to stay sober.

Treatment can further be complicated by the fact that those with PTSD often have other mental health issues, such as depression, anxiety, or bipolar disorder.2

From an assessment perspective, it can be difficult to discern which symptoms are attributable to PTSD or another mental illness, and which are a result of chronic substance abuse; this is why it’s extremely important that those with a dual diagnosis seek a treatment program that has extensive experience in treating both addiction and PTSD. These individuals require comprehensive and highly individualized treatment plans that address their unique needs.

Treatment Options

Group of people portraying PTSD patients in therapy group for treatmentIf you or someone you care about has co-occurring PTSD and substance abuse disorder, you will want to find a treatment program that specializes in treating those with dual diagnoses, particularly with those involving PTSD. Dual diagnosis recovery programs combine a variety of resources to ensure that both disorders are treated properly. When you’re researching potential recovery centers, it’s important to ask about staff experience with treating PTSD, substance addiction, and co-occurring disorders. It can also be useful to inquire as to what credentials are required of staff members.

There are several different types of recovery programs available, such as:

  • Inpatient: These programs require that you live at the facility for the duration of your recovery program. You receive 24-hour treatment and support while separating yourself from outside stressors and triggers. This option provides those with a dual diagnosis with the highest level of care necessary to recover from co-occurring conditions.
  • Partial hospitalization (PHP): These programs, also known as day treatment, are a step down from inpatient programs, providing intensive services while still providing the individual with the freedom to live at home. People in a day treatment program usually attend treatment 5 days a week for 4-6 hours each day. Some programs offer detox, while others do not. Other services include group and individual counseling and medical care. This option also provides individuals with PTSD and addiction extensive treatment and care.10,11
  • Intensive outpatient (IOP): These programs require less of a time commitment than PHPs, but like PHPs, they allow the individual to receive treatment during the day but return home in the evening. Patients receive a minimum of 9 hours of recovery services per week, typically meeting 3 days a week but sometimes meeting for as many as 5. These programs focus on group counseling, individual therapy, family involvement and counseling, community support, and monitoring of substance abuse.12
  • Standard outpatient: Individuals typically attend treatment 1-2 days per week for 1-2 hours each session. This may not be the best option for those with both PTSD and a substance use disorder, since these co-occurring disorders present unique challenges for the treatment provider and patient.

There is an increased risk of suicide in people who have PTSD. If you or someone you know is experiencing suicidal thoughts or is considering attempting suicide, call the National Suicide Prevention Hotline at 1-800-273-8255 or 911 immediately.

Types of Therapy

There are several types of therapy that are utilized in the treatment of PTSD and substance addictions. Overall, these therapies work to reduce PTSD symptoms and rectify negative patterns. Common types of therapy include:

  • Eye Movement Desensitization and Reprocessing (EMDR): EMDR helps individuals process the traumatic event they experienced. The person tracks an oscillating movement with their eyes while focusing on the traumatic memory. This can help to change how they view the memory and also reduce the stress and terror associated with it.13
  • Prolonged Exposure (PE): Individuals engaged in this type of therapy re-experience the traumatic event or situation via memories, feelings, or thoughts that they have been avoiding. Through this mechanism, PE has been shown to decrease the symptoms associated with PTSD.14
  • Cognitive Behavioral Therapy (CBT): CBT is a common therapy used for the treatment of alcohol or drug addictions. It focuses on the connection between behaviors, feelings, and thoughts and the therapist teaches people to identify and fix maladaptive behaviors, such as substance abuse. People in CBT learn a range of healthy coping strategies to help facilitate sobriety.15
  • Cognitive Processing Therapy (CPT): This type of therapy is geared towards those suffering from PTSD. It integrates elements of CBT to help change the person’s negative and unsettling thoughts associated with the trauma. Since thoughts, feelings, and behavior are all interconnected, replacing negative thoughts with positive ones can create more positive feelings.16

In addition to the above listed therapies, the two medications approved by the Food and Drug Administration (FDA) for the treatment of PTSD include Zoloft (sertraline) and Paxil (paroxetine). These two drugs are selective serotonin reuptake inhibitors (SSRIs), a class of medications that helps to regulate the brain’s levels of serotonin, a neurotransmitter affecting mood, appetite, sleep, and many other important processes. SSRIs are often used to manage the symptoms of depression and anxiety and many people who have PTSD also suffer from another mental health disorder, which is a main reason that these two drugs could be beneficial in reducing PTSD symptoms.17

How to Find Help

If you or someone you care about has PTSD and a co-occurring substance addiction, there is no need to suffer alone. No matter how severe your condition, recovery is possible with the proper treatment. Seeking formal treatment is the first step on the road to recovery and ultimately, a healthier and happier life.


References:

  1. Substance Abuse and Mental Health Services Administration. (2017). Post-traumatic Stress Disorder (PTSD).
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  3. S. Department of Veteran Affairs. (2017). Treatment of Co-Occurring PTSD and Substance Use Disorder in VA.
  4. Bremner, J. (2006). Traumatic stress: effects on the brain. Dialogues in clinical neuroscience. 8(4):445-461.
  5. S. Department of Veteran Affairs. (2015). PTSD and Substance Abuse in Veterans.
  6. Khoury, L., Tang, Y., Bradley, B., et. al. (2010). Substance use, childhood traumatic experience, and Posttraumatic Stress Disorder in an urban civilian population. Depression and anxiety. 27(12):1077-1086.
  7. S. Department of Veteran Affairs. (2015). PTSD and Problems With Alcohol Use.
  8. National Institute on Drug Abuse. (2010). Comorbidity: Addiction and Other Mental Illnesses.
  9. Berenz, E. & Coffey, S. (2012). Treatment of Co-occurring Posttraumatic Stress Disorder and Substance Use Disorders. Current psychiatry reports. 14(5):469-477.
  10. National Institute on Drug Abuse. (2014). Treatment Settings.
  11. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment. Rockville, MD: Substance Abuse and Mental Health Services Administration.
  12. Center for Substance Abuse Treatment. (2006). Substance Abuse: Clinical Issues in Intensive Outpatient Treatment. Rockville, MD: Substance Abuse and Mental Health Services Administration.
  13. S. Department of Veteran Affairs. (2017). Eye Movement Desensitization and Reprocessing (EMDR) for PTSD.
  14. S. Department of Veteran Affairs. (2017). Prolonged Exposure for PTSD.
  15. National Institute on Drug Abuse. (2012). Cognitive-Behavioral Therapy (Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine).
  16. S. Department of Veteran Affairs. (2017). Cognitive Processing Therapy for PTSD.
  17. S. Department of Veteran Affairs. (2017). Clinician’s Guide to Medications for PTSD.

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