Why PTSD and Substance Abuse are Related?
Everyone will experience stressful events in life, and many people will experience extremely stressful events; however, not everyone will develop a severe stress-related reaction to these events. Post-traumatic stress disorder (PTSD) is a mental health disorder that occurs after experiencing or witnessing a very traumatic event.
Specifics of PTSD
Individuals who develop PTSD are either directly involved in a traumatic experience, witness a traumatic event happen to other people, or, in some cases, hear of a very traumatic stressful event happening to someone close to them, such as a relative or close friend. Early in its conception, PTSD was considered to occur only as a result of the direct experience of some traumatic event, such as combat experiences; however, over the years, researchers in clinical psychology and psychiatry have expanded the range of situations that may produce PTSD in some individuals.
Initially, it was believed that disorders related to trauma and stress were primarily manifestations of anxiety; however, it became clear that a number of different processes in addition to anxiety were driving these disorders. In 2013, the new classification system by the American Psychiatric Association (APA) included a new diagnostic category Trauma– and Stressor-Related Disorders. This category was developed for disorders like PTSD and related conditions to signify that these were unique disorders that contain a number of different symptoms. The category is situated between the Obsessive-Compulsive and Related Disorders category and the Dissociative Disorders category in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) indicating that disorders that result from traumatic and stressful experiences have similarities to these two particular diagnostic categories.
As mentioned above, the person does not actually have to directly experience a stressful or traumatic event in order to be diagnosed with PTSD. There are several different avenues of experiencing a stressful or traumatic event that are believed to be associated with the development of PTSD in some individuals that include:
- Obviously directly being involved in a traumatic or stressful event
- Witnessing a very traumatic event as it happens to others
- Learning that a loved one has experienced some traumatic or stressful event
- Being repeatedly exposed to the aftermath of a severe traumatic incident, such as being a rescue worker who repeatedly sees the effects of a hurricane on other individuals
The most common types of stressful and traumatic events that are associated with the development of PTSD are:
- Combat experiences
- Rape or attempted rape
- Other types of physical abuse or physical assaults, either attempted or completed (especially in childhood)
- An accident, such as an automobile, airplane, or train accident
- Involvement, witnessing, or hearing of someone being involved in a kidnapping attempt, an act of terrorism, or in a natural disaster, such as a hurricane
- The diagnosis of a very serious medical condition, such as cancer, HIV, etc.
Because the diagnosis of PTSD can occur as a result of witnessing or hearing of someone else being involved in these types of events, the actual diagnosis of PTSD is left to interpretation by the specific clinician involved in the diagnostic process. It should be noted that the diagnosis of PTSD is not given when an individual hears of a stressful or traumatic event happening to others over the media, unless the specific event happens at the individual’s workplace. The diagnosis of PTSD requires that an individual exhibit some very specific types of symptoms that guide the clinician in a more objective manner.
The Diagnosis of PTSD
According to the American Psychiatric Association, the types of symptoms that occur in individuals who are diagnosed with PTSD include:
- Re–experiencing the traumatic event in the form of intrusive thoughts, flashbacks, or recollections in the form of nightmares or very vivid memories
- Repetitive attempts to avoid situations that remind the person of the traumatic event (may include media events, such as movies and TV shows)
- Very strong feelings of anxiety associated with any stimuli that remind the individual of aspects of the event
- Feelings of detachment from the self, reality, or others
- Anhedonia, which is the inability to experience pleasure
- Ongoing feelings of dysphoria (negative emotions that include depression, irritability, anxiety, etc.)
- Significant amotivation (a lack of motivation to do things or participate in events that were of prior interest)
- Mood swings
- The development of suspiciousness or a pessimistic attitude regarding one’s own future, the world in general, or other individuals
- Social isolation
- Hypervigilance to certain aspects of the environment that remind the individual of the traumatic event or signal that a similar event could happen
- Flat affect (difficulty feeling or expressing emotions)
- Memory loss for specific aspects of the traumatic event
- Cognitive difficulties that can include problems with attention, focusing, problem-solving, and remembering new information
- Feeling suicidal or actually engaging in self-harm
- Engaging in self-destructive behaviors, such as substance abuse, violent acts toward others, etc.
Special considerations in the formal diagnostic criteria of PTSD are made for children under the age of 6. The actual diagnosis of PTSD is made according to the number of symptoms an individual consistently displays within a specific period of time. In order to be diagnosed with PTSD, the actual symptoms that an individual displays must occur for more than one month. For individuals who have experienced a stressful or traumatic event (or witnessed or heard about it) and display symptoms that suggest PTSD for less than a month, a diagnosis of acute stress disorder can be made. Many individuals who experience a traumatic or stressful event have acute reactions to them, and the symptoms dissipate within 3-4 weeks. Once the individual consistently displays the symptoms of PTSD for more than one month, they are given a diagnosis of PTSD.
PTSD can develop relatively soon after the experience, or in some cases, it may take weeks, months, and even years for the full syndrome to develop. When PTSD develops months to years after the experience of a traumatic event, it becomes quite difficult to initially connect the event to the symptoms the individual expresses, and often, these individuals are given a number of other diagnoses that can include anxiety disorders, major depressive disorder, personality disorders, and others before PTSD is identified.
Who Is at Risk to Develop PTSD?
The obvious answer to the above question is that individuals who experience extremely traumatic or stressful events are at risk to develop PTSD. However, there are number of other risk factors that are associated with the development of PTSD. A risk factor is not the direct cause; risk factors simply increase the probability that an individual may develop a disorder or disease. Risk factors are also cumulative, such that individuals who have multiple risk factors are at higher risk to develop the specific disorder in question compared to individuals with only one risk factor.
- Being female is associated with an increased risk of developing PTSD; however, this is probably more reflective of the fact that women are often the victims of specific types of traumatic experiences, such as aggression, rape attempts, etc.
- Certain high-risk occupations increase the likelihood of the development of PTSD. Members of the US Armed Forces, firefighters, and first responders have a higher risk for the development of PTSD.
- The actual traumatic or stressful event also plays a role. Obviously, certain types of events are associated with higher rates of PTSD, such as being part of active-combat duty in the military, a rape victim, etc. Also, the actual perception of the severity of the event and its aftereffects are associated with a higher risk to develop PTSD.
- Having a history of psychological problems that can include a history of depression, a personality disorder, an anxiety disorder, a substance use disorder, or previous PTSD or PTSD-like symptoms are associated with higher risk for the development of PTSD. In addition, having a first-degree relatives diagnosed with a mental health disorder can increase the risk for developing PTSD under the right circumstances.
- Having a lower level of education, coming from a background of poverty or lower economic status, and childhood stress/adversity also increase the risk of developing PTSD.
Of course, the above risk factors are only risk factors for individuals who actually experience, witness, or hear of another person being involved in a traumatic or stressful event. The first and foremost risk factor to developing PTSD is actual experiencing or witnessing a traumatic event.
PTSD and Substance Use Disorders
Individuals who are diagnosed with PTSD are at a far higher risk to develop substance use disorders than individuals in the general population who are not diagnosed with PTSD. A general figure often quoted in the literature is that around the 20 percent of individuals who seek treatment for PTSD or PTSD symptoms also have a co-occurring substance use disorder. Certain symptom profile files that occur in individuals with PTSD also appear more likely to be associated with significant substance abuse or the development of a substance use disorder. Individuals who experience flashbacks, intrusive thoughts, or other types of re– experiencing the traumatic event appear to be at a higher risk to develop a co-occurring substance use disorder than individuals with PTSD who do not have these experiences.
People diagnosed with PTSD can also have a co-occurring substance use disorder that can include nearly any type of substance of abuse. The most common substance use disorders that occur in conjunction with PTSD include alcohol use disorders, opiate use disorders (e.g., heroin, morphine, Vicodin, etc.), benzodiazepine use disorders (e.g., Xanax, Ativan, Klonopin, Valium, etc.), cannabis use disorders, and stimulant use disorders (particularly very strong stimulant drugs, such as cocaine and methamphetamine). Because many of these individuals abuse prescription medications and have co–occurring complaints of pain, anxiety, depression, etc., the prescription of medications for these symptoms should be done judiciously, and the person’s use of these medications should be monitored very strictly. In addition, due to the complicated picture these individuals often present with, the potential for an individual with PTSD developing substance use disorders to multiple drugs of abuse is quite real.
The relationship between the development of PTSD and substance use disorders is very complex. Many individuals are tempted to immediately invoke the notion of “self-medication” where the individual with PTSD turns to substances as an attempt to treat their own symptoms. However, a very salient risk factor to develop PTSD is having a prior substance use disorder; individuals who had pre-existing substance use disorders before they experienced the traumatic event are more likely to develop PTSD than individuals without a history of substance use disorders. This indicates that the relationship between these two disorders is much more complicated than the simple notion of individuals trying to medicate themselves.
A model that explains the bidirectional relationship between substance use disorders and other mental health disorders is known as the shared liability model. The shared liability model suggests that individuals who develop substance use disorders and other mental health disorders share a number of similar factors, such as genetic associations, neurobiological pathways, and environmental experiences that make them more prone to developing multiple and co-occurring mental health disorders. Indeed, it is observed in a number of different sources that individuals who have one type of mental health disorder are often at a significantly higher risk to develop other mental health disorders, including substance use disorders.
Addressing PTSD and Substance Use Disorders
PTSD is often treated by using a combination of medications to address specific symptoms, such as depression, anxiety, etc., and psychotherapy that is targeted at helping the individual address the reaction to the trauma, the symptoms they experience, and reevaluate their experience in a more positive and productive manner. Therapy often consists of combinations of individual and group therapy sessions with other individuals who have PTSD and may also include family therapy to address domestic issues that have occurred as a result of the development of PTSD in the individual. The treatment is often very complicated, and in severe cases, it can be quite lengthy.
An individual who has developed PTSD and a co-occurring substance use disorder presents with an even more complicated situation. It is counterproductive to attempt to treat one disorder without addressing the other at the same time. Therefore, individuals with comorbid mental health disorders need to have these disorders treated concurrently. This means that the individual would be treated for PTSD with medications and psychotherapy while also receiving treatment for their substance use disorder. Substance use disorder treatment could include an initial withdrawal management program, medical management of other symptoms such as cravings, counseling and therapy for substance use disorders, participation in social support groups such as 12-Step groups (e.g., Alcoholics Anonymous), and other interventions as needed in the individual case, including vocational rehabilitation, physical and/or occupational therapy, case management services, etc.