The Relationship Between Post-Traumatic Stress Disorder and Addiction
There is no such thing as living a life devoid of stress or potentially stressful experiences. Everyone will experience some form of stress at least once in life, and most everyone will experience numerous stressful events. In addition, many people experience stressful events that are extremely distressing and even traumatic, such as losing a spouse, losing a parent, losing a child, being fired from a job, being in a terrible accident, being involved in a natural disaster, etc. The vast majority of individuals who experience stressful events that are associated with some form of trauma do not develop severe mental health disorders. However, some individuals who experience these types of events do develop severe psychological reactions that qualify for a formal diagnosis.
Post-traumatic stress disorder (PTSD) is a mental health disorder that develops in some individuals who have been exposed to, witnessed, or otherwise learned of a traumatic experience happening to someone they care about. PTSD represents a severe psychological reaction to trauma, and its development is associated with a number of risk factors.
A psychological disorder like PTSD is diagnosed when the person develops a number of dysfunctional behaviors, symptoms, reactions, etc., that are rigid and affect the person’s ability to function normally. Simply being depressed after the loss of a loved one (bereavement) is not necessarily a sign of PTSD unless it is clinically judged that the intensity or length of the individual’s bereavement is dysfunctional.
Because the diagnosis of PTSD requires a formal assessment by a licensed mental health clinician, it is important to remember that anyone who suspects that they, or someone else, suffer from a mental health disorder like PTSD consults with a licensed professional. The information in this article cannot be used to formally diagnose any person with any type of mental illness.
What Is PTSD?
PTSD is a complex disorder. It presents with a number of different symptoms that may vary from individual to individual. There is no accurate way to formally predict who will develop PTSD as a result of experiencing some stressful event or situation. Over the years, research has indicated that PTSD can develop in some people who witness a stressful event happening to others or who learn about a stressful event happening to a close friend or other loved one.
The type of stressful event that can produce PTSD can be quite varied; however, it must involve some degree of exposure to an actual or threatening serious situation, sexual violence, or a potential situation that can result in the death of oneself or others. Some of the more common types of traumatic events associated with the development of PTSD include:
- Combat experiences
- Physical or sexual assault
- Severe accidents, such as automobile accidents, plane accidents, etc.
- Severe natural disaster, such as a tornado, hurricane, earthquake, etc.
- Terrorism-related event
Again, it is not necessary for an individual to actually be the victim of one of these situations. PTSD may develop in some people who learn that a close friend or relative experienced one of the situations listed above, who witness individuals struggling in the above situations, or who are somehow involved in the situation’s aftermath, such as first responders who supply medical care to individuals of natural disasters or terrorist acts.
A Complicated Disorder
This disorder has included a number of different changes in its conceptualization. Early on, the disorder was considered to only develop as a result of direct experience in some traumatic event, such as combat or attempted rape. As clinicians and researchers became more aware of the symptoms of the disorder, it was learned that individuals who experienced harrowing accidents or who were involved in natural disasters also sometimes displayed the symptoms associated with the disorder.
The disorder was also historically classified as an anxiety disorder – a disorder where the primary symptoms displayed by individuals who have it are related to anxiety. However, the American Psychiatric Association (APA) recently removed PTSD from the category of anxiety disorders and assigned it to a new category: trauma and stressor-related disorders. Research into PTSD and related disorders indicated that anxiety was indeed one of the major symptoms that occurred in individuals diagnosed with these disorders; however, there were a number of other symptoms, such as depression, dissociation, anger, cognitive issues, etc., that were equally salient in those diagnosed with PTSD and related conditions. As a result, PTSD is no longer considered to be primarily a manifestation of dysfunctional anxiety, but instead is considered to be a complicated and severe mental health condition that represents the interplay of many different processes.
Because this is a complicated disorder, clinicians diagnosing it need to understand the symptom profile of the disorder and the complete presentation and history of the person who is being considered for the diagnosis. There are no formal medical tests, such as laboratory tests or neuroimaging scans, that can diagnose PTSD. Instead, clinicians must evaluate the person based on their behaviors. The information used to diagnose a person is often gleaned from the person themselves and individuals close to the person.
Because the diagnostic process for psychiatric disorders requires understanding the intricacies of human behavior, significant training and supervision are required for clinicians to be able to accurately diagnose these conditions. According to the current diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) released by APA, the general presentation of PTSD includes the following types of symptoms (These are not the specific diagnostic criteria but represent signs and symptoms based on the formal diagnostic criteria.):
- Exposure to a potentially fatal situation, serious injury, or sexual violence, either by directly being involved in the event, witnessing the event as it occurs to others, learning that the event has happened to someone close, or being repeatedly exposed to the details of traumatic events, such as medical personnel, police officers, firefighters, etc. (This is the only required sign; other signs may or may not be present but a person must express a specific number of them.)
- Experiencing significant anxiety when one is reminded of details of the event
- Having repeated recollections or lucid reexperiences of the event, such as nightmares, intrusive thoughts, actual flashbacks, etc.
- Feeling isolated and detached from other people
- Feeling as if things are not real (being detached from reality)
- Repeated attempts to avoid things that remind the person of the traumatic event
- Constantly lacking motivation
- Being unable to experience pleasure in situations that once brought pleasure
- Experiencing significant mood swings
- Continually experiencing negative emotions, such as irritability, restlessness, anxiety, depression, etc. (often referred to as dysphoric reactions)
- Having a pessimistic attitude about the world, the future, or oneself
- Hypervigilance regarding certain types of stimuli that might trigger the reaction one had to the stressful event
- Being suspicious of others
- Flat affect (difficulty with overt emotional expression)
- Having difficulty recalling specific aspects of the traumatic event that others would be able to recall
- Other cognitive problems, such as issues with attention, memory, problem-solving, receptive language, etc.
- Continued efforts to isolate oneself from contact with others
- Feeling suicidal or engaging in self-harm, such as cutting oneself
- Engaging in other self-destructive behaviors, such as substance abuse, numerous instances of unprotected sex, etc.
The formal diagnosis of PTSD in children under the age of 6 is based on alterations of the formal diagnostic criteria that are age-appropriate. The symptoms that the individual expresses must not be better explained by some other medical condition, a substance abuse, or some other mental health disorder. Individuals need to display several symptoms from different categories in order to receive a formal diagnosis, and the symptoms must have been present for more than one month. Individuals presenting with similar symptoms that have not been present for at least one month are diagnosed with acute stress disorder, which may or may not develop into a formal PTSD diagnosis. The diagnosis can be made in situations where the symptoms do not occur for six months or longer after the exposure to the event (termed PTSD with delayed expression).
While it appears that the specific type of traumatic event one experiences is not a justifiable criterion to diagnose specific subtypes of PTSD based on the symptom profile (e.g., combat-related PTSD, rape-related PTSD, accident-related PTSD, etc.) as the presentation of the disorder differs significantly over all different types of traumatic events, there is one recognized subtype of PTSD, according to DSM-5. This subtype of PTSD is termed PTSD with dissociative symptoms. Dissociative symptoms are symptoms that occur when individuals either feel detached from themselves (depersonalization, such as feeling as if one is leaving one’s body) or from other aspects of reality (derealization, feeling as if things are not real). Again, it should be noted that most individuals have these experiences from time to time. The diagnosis of a formal disorder requires these experiences to be relatively frequent to the point of being almost constant and fixed. Other different proposed subtypes of PTSD do not as of yet have sufficient empirical evidence to be accepted in the DSM-5.
Who Develops PTSD?
The obvious answer to this question is that individuals who witness, learn of, or experience traumatic events may develop PTSD. However, the vast majority of individuals with these experiences do not develop the disorder. Thus, while some type of exposure to a potentially traumatic or stressful event must be present before one can be considered for a diagnosis of PTSD, simply having this exposure is not sufficient for the diagnosis to be made.
As it turns out, there are no foolproof methods to predict which individuals experiencing these types of traumatic events will actually develop PTSD. However, research has identified a number of risk factors associated with individuals who develop the disorder. It should be understood that a risk factor does not represent a specific or direct cause, but instead represents a condition that increases the probability that one will develop a disease or disorder. Having numerous risk factors will increase the probability further.
Research has indicated that there are some significant risk factors associated with the development of PTSD. These are outlined below.
- Obviously, an individual who is employed in certain types of professions has an increased risk of being exposed to stressful and traumatic events and therefore would have an increased risk of developing PTSD. This certainly includes those in the military. Other types of high-risk professions include healthcare workers who are first responders to crimes or natural disasters, firefighters, police officers, hospital workers, etc.
- Even though women are at higher risk to develop PTSD than men, this is most likely related to the fact that women are victims of serious crimes, such as rape and assault, more often than men.
- One’s level of education may increase the risk for the development of PTSD in response to perceived trauma. Individuals with lower levels of education appear to be diagnosed more often with PTSD than individuals with higher levels of education.
- The particular type of traumatic event is also associated with the development of PTSD. For instance, PTSD is more often diagnosed in rape victims and individuals who have direct combat experience in the military than in individuals who experience automobile accidents or other types of potentially stressful events. In addition, the subjective perception of the severity of the threat one experiences is associated with a greater risk to develop PTSD.
- Having a previous diagnosis of a mental health disorder or having a first-degree relative with such a diagnosis also appears to be associated with a higher risk to develop PTSD. This includes having a previous diagnosis of a substance use disorder.
- According to APA, having a history of childhood adversity, such as abuse or parental divorce, may also be associated with an increased risk to develop PTSD.
Substance Use Disorders and PTSD
There is a large body of research indicating that people who are diagnosed with PTSD are significantly more likely to be diagnosed with a co-occurring substance use disorder than individuals in the general population. A number of sources, including APA, suggest that up to 20 percent of people who seek treatment for PTSD also have a co-occurring substance use disorder.
Research has also suggested that individuals with PTSD who express certain types of symptoms, including flashbacks and other very intense reexperiences of trauma (e.g., nightmares), or who have numerous intrusive thoughts are more likely to be diagnosed with co-occurring substance abuse. Any type of substance of abuse can be associated with a diagnosis of PTSD, but it appears that the drugs that are most often abused in individuals with PTSD are alcohol, central nervous system depressant drugs (e.g., narcotic pain medications and antianxiety drugs, such as benzodiazepines), cannabis products, and cocaine. Individuals with PTSD are also very likely to abuse multiple drugs.
At this point, readers may have concluded that individuals with PTSD use substances to self-medicate their symptoms. While this certainly happens, the relationship between PTSD and substance use disorders is not as straightforward as one may be inclined to believe. As mentioned above, one of the salient risk factors associated with the development of PTSD is a prior diagnosis of a substance use disorder or a history of substance abuse. Thus, the relationship between substance use disorders and PTSD is bidirectional and most likely represents a general type of vulnerability to mental health disorders that occurs in specific individuals. This vulnerability, sometimes referred to as the shared liability model, may be based on genetic factors, environmental experiences, or a combination of both interacting with each other.
Treatment for PTSD and Addiction
At the current time, there are no approved medications specifically designed to address PTSD. Medications are commonly used in the treatment of PTSD, but these medications are most often used to address the specific symptoms that the individual is displaying, such as depression, anxiety, suspiciousness, etc. Medication alone is not sufficient to deal with PTSD, and most often, a combination of medication and therapy is the preferred course of treatment.
According to scholarly sources, such as the book Effective Treatments for PTSD, the types of psychotherapy most often used in the treatment of PTSD are based on cognitive-behavioral methods where individuals are required to identify dysfunctional thoughts, determine how these thoughts lead to their behavior, and then learn to alter their thought processes and alter their behavior.
In addition, certain types of exposure treatments in conjunction with relaxation training may be used. Exposure occurs when individuals with certain anxiety-provoking beliefs or experiences are directed by the therapist to either imagine the experience or to recreate the experience and then confront it. Often, this confrontation occurs after the person has been trained in muscle relaxation and diaphragmatic breathing. This allows the person to expose themselves to the source of their distress in a relaxed state. This type of therapy can only be safely performed by highly skilled and trained professionals, and when used properly, it can be effective for some individuals; however, individuals who experience psychotic reactions, such as hallucinations or delusions, or who have very severe symptoms should not be administered exposure techniques unless the therapist has experience in treating such cases.
PTSD and co-occurring substance use disorders must be treated concurrently. Simply trying to address one disorder and ignore the other will not result in either disorder being effectively treated. The type of treatment program recommended for use in co-occurring disorders is often referred to as an integrated treatment program. Integrated treatment is delivered by an interdisciplinary team of therapists and physicians who each address specific aspects of the co-occurring disorders over the same period of time. This allows for the treatment program to be individualized according to the needs of the client and at the same time remain comprehensive and effective. Typically, integrated treatment for co-occurring PTSD and a substance use disorder consists of:
- Initial inpatient treatment, particularly in cases where individuals need to be placed in physician-assisted withdrawal management programs
- Medical management of these conditions as required, including medications and other interventions
- Therapy targeted at PTSD and therapy aimed at the substance use disorder
- Group therapy for both PTSD and substance use issues
- Active participation in social support groups, such as 12-Step groups
- Other types of therapy, such as family therapy, if needed
- Other interventions that are relevant to the specific case. These can include issues with job training, tutoring at school, occupational therapy, speech therapy, etc.
- Long-term aftercare, social support group participation, and other monitoring
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