Post-Traumatic Stress Disorder and Substance Use

Author: Bertha K Madras, PhD

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a state of mind activated by either witnessing or experiencing a shocking, frightening, horrifying episode(s). The ordeal can involve threats of or actual physical violence to themselves, to family or friends they are bonded with, or strangers. Some individuals who have experienced a terrifying event may find it difficult to cope and adjust for some time, but gradually they improve as the emotional memories fade. If symptoms continue or get worse after prolonged periods of time (months or years later), interfere with daily life and function, and persist long after there is no danger of a recurrence, the condition is designated post-traumatic stress disorder. In PTSD, memories of the original trigger persist, along with feelings of distress, fear, or trauma. The constellation of symptoms can range from nightmares, flashbacks, to severe anxiety, as thoughts and memories reply the events and cannot be suppressed. 

Who Is at Risk for PTSD?

Veterans with combat experience are at great risk for PTSD, but civilian populations also harbor this persistent condition. Experiencing or witnessing rape; torture; kidnapping and captivity; child abuse; car, train, or airplane accidents; natural disasters such as hurricanes, floods, or earthquakes; and unexpected death of a family member or friend are examples of traumas that can trigger PTSD in vulnerable populations. 

What Are PTSD Symptoms?

A short-term symptoms of anxiety and stress are common following a traumatic event, as most people respond with some functional disability immediately afterwards. A full constellation of persistent PTSD symptoms, lasting at least a month or years, indicates a disease state. Symptoms may surface within a few months of the events, or, in some individuals, years later. They may fluctuate between intense and weak, depending on environmental and personal “triggers,” such as repeated exposure to unrelated traumatic events or cues. The symptoms can be severe enough to interfere with work, relationships or social function. Recovery may take fewer than 6 months, or persist much longer or become chronic. Symptoms can include (a) intrusive memories, (b) avoidance, (c) negativity, (d) hyperemotional responses.

Intrusive memories can be experienced over and over in the form of unwanted flashbacks, bad dreams, or reliving the traumatic event, with severe distress or reactions to situations that conjure up the event. Triggered by memories, situations, sounds, or words, the intrusive memories can interfere with everyday life.

Avoidance is a complicated reaction to an episode. It can manifest by staying away from people, places, objects or activities that remind the person of the experience (for example, driving), by losing interest in pleasurable activities, or with problems remembering the event.

Negativity manifests as an unenthusiastic, pessimistic outlook on life, which may include negative feelings about oneself or others, emotional numbness, loss of interest in enjoyable activities, hopeless outlook for the future, difficulty with memory or maintaining relationships.

Hyperemotional responses may manifest as tension, sleep difficulties, angry outbursts, stress, irritability, aggression, hyper-vigilance for dangerous situations, hyper-startle, all symptoms that can interfere with daily life.

Can PTSD Be Predicted?

It is challenging to predict who will or will not develop PTSD after a traumatic event. Predisposing factors may include underlying mental health problems such as anxiety and depression, the nature and extent of other adverse life experiences, temperament (genetic predisposition), brain response to stress, and exposure to multiple traumatic events. PTSD can occur in men, women, and children, with women more likely to develop PTSD than men. Susceptibility may run in families but powerful experiences such as being a victim, or witnessing others hurt or killed, and feeling helpless, or extreme fear can generate the symptoms. The risks of PTSD after a traumatic experience can be compounded by inadequate social support or additional stressors (pain, death in family, work problems). The risks of PTSD can be attenuated by support from family, friends, support groups and powerful emotions that counter the trauma. When confronted with danger, a resilient person will perceive their response as appropriate, pro-active and effective.

PTSD Treatment

The main approaches to PTSD treatment are psychotherapy, medications, social support, or a combination of all:

• Cognitive therapies designed to diminish negative perceptions of normal scenarios, to make sense of haunting memories;
• Exposure therapy designed to enable facing, confronting, coping and controlling the fears that triggered PTSD;
• Other psychotherapies designed to explain how trauma affects individuals, to transform reactions to PTSD symptoms, to teach anger management skills, to identify and reduce guilt, shame, or other negative feelings.

These approaches can be combined with antidepressants or anti-anxiety medications to relieve symptoms of PTSD.

PTSD and Substance Abuse

PTSD and substance use disorders are interlocked by shared genetic and environmental factors. Alcohol and other substance use disorders are very common in people with posttraumatic stress disorder. Of people seeking treatment for substance use disorders, approximately 50% harbor the symptoms of PTSD, a percentage 5 times higher than PTSD in the general population. Because of the high rates of this co-occurrence, it is likely that PTSD and substance use disorders are related to one another.

Whether PTSD causes substance use disorders has not been proven. Evidence is accumulating that PTSD precedes and predicts the development of a substance use disorder rather than the reverse. Individuals apparently use substances to cope with PTSD and its negative moods. Initially, alcohol and other drugs are consumed to relieve PTSD symptoms. However, if a substance use disorder develops, there is an inherent risk of increasing PTSD symptoms, especially during the withdrawal phase. In the midst of the PTSD hyper-arousal state, withdrawal from substances can accelerate relapse to substance use. It is clear that during detoxification, meticulous control of drug withdrawal and PTSD arousal symptoms should be implemented.

The relationship between PTSD symptoms and consumption of alcohol and other drugs is robust. When one condition deteriorates, the other condition also worsens. When PTSD symptoms are greater, alcohol craving also intensifies. Indeed, in a laboratory setting, when alcohol dependent individuals with PTSD are presented with a trauma cue, they report an increase in their alcohol craving. Conversely, if PTSD symptoms decline, substance use decreases. Treatment of the substance use disorder in PTSD individuals results in a significant decrease in PTSD symptom severity, even if PTSD is not being treated. Treatment needs to be tailored to the individual, for substance use disorders and PTSD affect individuals differently.

PTSD is an added liability for successful treatment of a substance use disorder. Treatment success is greater in populations with a substance use disorder alone, compared with populations that harbor both a substance use disorder and PTSD. PTSD patients undergoing treatment for a substance use disorder describe more intense cravings for drugs and/or alcohol and are prone to relapse more quickly after completing a treatment protocol. Currently, there is no consensus on best approaches for treating people with both diagnoses, but treating both is essential.