PTSD and Addiction

The Facts About PTSD and Substance Abuse, Including Symptoms, Causes, and Treatment Options

Find out how to get help for PTSD and substance abuse (or another kind of addiction). A better life really is possible.

Your past experiences don't have to impact your future. In fact, with support, you can restore your mental health and physical well-being and start living in a way that feels a lot more empowering. You'll have the chance to overcome the disruptive feelings that still haunt you so that they no longer interrupt your life. And you'll begin to learn what it means to move beyond just surviving—to a place in which you actually get to thrive.

So discover a new path forward. Even if you have both PTSD and an addiction to drugs, alcohol, or certain behaviors, you can recover.

What Is PTSD?

PTSD, or post-traumatic stress disorder, is a severe reaction to overwhelming stress from a trauma or a traumatic event. Such events can include physical, sexual, or psychological violence. They can involve natural or man-made disasters, accidents, sudden loss, severe illness, combat, or being witness to the aftermath of adverse events. They can also involve not having basic needs met during periods of starvation, homelessness, or exposure to the elements.

PTSD is not diagnosed by the specific event a person encounters, but rather by what kind of response a person has to it. People respond to trauma in different ways, and the majority of people who experience a traumatic event do not develop PTSD (Friedman, 2014). For example, several people may be present during a serious car accident, but not all of them will develop the condition. For those who do, PTSD is a difficult challenge and can interrupt their lives until it's resolved.

What Causes PTSD?

It's impossible to name every event that may cause this condition, but there are some general guidelines about the kinds of events that do. For example, events that can cause PTSD are often those in which at least one of the following occurs:

• Actual death
• The threatened or possible death of one's self or another
• Actual serious injury to one's self or another, whether it be physical or psychological
• The threatened or possible serious injury to one's self or another
• Actual sexual violence against one's self or another
• The threatened or possible sexual violence against one's self or another

Being exposed to such events can happen in several ways:

• Directly—Being the endangered or threatened person or the actual victim
• As a witness—Watching another person be endangered, threatened, or victimized
• Indirectly—Learning about an event that involved a close family member or friend dying violently or accidentally, or learning that he or she was exposed to trauma
• Occupationally—Through performance of job duties—such as first responders who are at scenes of trauma, or therapists who repeatedly have indirect information about traumatic events from records and client accounts (American Psychiatric Association, 2013a)

That's why, for example, there is a strong link between PTSD, veterans, and substance abuse. As a group with one of the highest rates of PTSD, military service members are often at great risk of developing this kind of mental health condition later on—sometimes along with addiction. That's especially true of anyone who has been involved in combat.

Why Doesn't Everyone Who Experiences Trauma Get PTSD? Facts About Resiliency

Certain factors can reduce the risk of developing PTSD after a traumatic event. They include personality characteristics, behaviors, self-image, social relationships, and mental and emotional skills. Having protective factors in one's life is known as resiliency, which is the ability to bounce back after stressful situations and trauma. Some characteristics of resiliency are:

• Having and using support from other people or reaching out and accepting help
• Having relationships that are loving, create trust, and provide good role modeling, encouragement, and reassurance
• Being able to manage strong feelings, urges, and impulses
• Carrying on with everyday life even though feelings are strong
• Making time to express feelings about an event
• Self-care, including taking action or resting when needed
• Feeling good about one's own actions during a traumatic event—for example, thinking that everything that could be done was done
• Having a strategy for coping with trauma, making realistic plans, and carrying them through
• Having a positive self-image and feeling confident in one's strengths and abilities
• Having problem-solving skills
• Having good communication skills
• Talking about a trauma in appropriate places and with supportive people (APA, 2014; Charney, 2004)

Common PTSD Symptoms

With PTSD, signs and symptoms occur after a trauma (hence the term post-traumatic). They also vary and are often classified into four groups:

1. Re-experiencing or Intrusion Symptoms—Oftentimes, PTSD causes symptoms that intrude and disrupt daily routines. They create a feeling of reliving the trauma to some degree. Examples are:
   • Recurring memories that are involuntary, unwanted, and distressing
   • Nightmares
   • Dissociation (e.g., not being in the present moment, having flashbacks or periods of no awareness of your surroundings, having memory gaps, or feeling that you have lost periods of time)
   • Feelings of distress when exposed to reminders of the trauma
   • Intense bodily reactions such as sweating, rapid heart rate, or shaking when exposed to reminders
2. Avoidance Symptoms—These are ways in which a person attempts to avoid distress. This is done through:
   • Making persistent efforts to avoid thoughts or feelings about the trauma
   • Making persistent efforts to avoid reminders of the trauma (e.g., people, places, conversations, activities, objects, or situations)
3. Mental and Mood Symptoms—These are ways in which mental functioning and emotions are changed by trauma. They can include:
   • Having amnesia for key features of the trauma
   • Having distorted beliefs and expectations about yourself or the world because of the trauma (such as thinking that all men are dangerous because one harmed you, or thinking you could have saved people when it was not possible)
   • Erroneously blaming yourself or others for the trauma
   • Continuing to have negative emotions related to the trauma such as fear, horror, anger, guilt, or shame
   • Notably losing interest in significant activities that were enjoyed prior to the event
   • Feeling alienated, detached, or estranged from others
   • Having limited emotions or the inability to experience happiness
4. Changes in Arousal and Reactions—These are changes in one's level of excitability, which can include:
   • Displaying irritable or aggressive behavior
   • Behaving self-destructively or recklessly
   • Being hypervigilant and excessively watchful, including scanning your environment for threats
   • Startling easily or being startled by sounds, sights, movements, or other occurrences that wouldn't normally startle others as easily
   • Having problems with concentration
   • Having sleep problems (Adapted from the DSM-5 American Psychiatric Association, 2013b)

Fight, Flight, or Freeze: Another Way to Think About the Cause of PTSD

Psychological trauma is caused by an intense body and brain reaction in survival situations. Instincts cause us to fight, flee, or freeze in the face of danger. The body either "tenses in readiness, braces in fear" or "freezes and collapses in helpless terror" (Levine & Fredrick, 1997). Each kind of reaction is involuntary and not under conscious control. They're caused by instincts that are meant to give us the best possible chance of surviving a dangerous situation. When the danger is over, our bodies and brains should return to normal, no longer having an intense survival reaction. However, for people with PTSD, that isn't the case. The brain and body are not convinced that the danger is over when one has PTSD. The symptoms listed in the previous section are evidence of the brain continuing in survival mode even when danger has passed.

Why Are PTSD and Addiction Often Connected?

The relationship between PTSD and drug abuse, alcoholism, or compulsive behavior is complex, and occurs in many ways. Consequently, it's recommended that, when both conditions are present, they both get treated at the same time. That's because of their significant interactions with one another and the great possibility that leaving one untreated will allow problems to continue.

The combination of PTSD and substance abuse (or other forms of addiction) is more common than you might think. It's estimated that about 50 percent of people who go to treatment for addiction also have PTSD (Bonin, Norton, et al, 2000). In addition, people with PTSD are considered to be at a much higher risk for substance abuse and addiction than people without it (Duckworth, 2011). The two conditions seem to lead to one another from both sides of the fence. Some PTSD research has looked at why there's such a strong connection and how this happens.

According to some PTSD studies, one possible connection is that the disorder causes so much distress that people self-medicate with drugs or alcohol. Self-medication can involve the abuse of prescriptions, over-the-counter medications, alcohol, or illegal substances. And it can be hazardous—worsening both PTSD symptoms and the harmful effects of substance use. The negative consequences include the potential of becoming addicted or deepening an addiction, becoming depressed and suicidal, and becoming more vulnerable to additional traumas such as the loss of employment, housing, or relationships (Leeies, Pagura, Sareen, & Bolton, 2010).

Another possible cause of the strong relationship between drugs, compulsive behavior, alcohol, and PTSD is that some people are already vulnerable to addiction or post-traumatic stress when a trauma happens. For example, those who are already using substances to cope with stress may be more biologically vulnerable to PTSD when a trauma occurs. Also, substance users may be more vulnerable to PTSD because they have already had trauma in their lives. For example, many substance abusers have a history of physical or sexual abuse as young people (Herman, 1992; Miller, 1994). A series of traumatic events can cause the impact of new stressful events to be magnified.

Addicted people, in general, are at a high risk for trauma. Substance use causes poor judgment, poor decision-making, lowered defenses, and "the willingness to engage in risky behaviors" such as going into dangerous situations with dangerous people. Addicts are also at risk for injury and emergency-related physical trauma (SAMHSA, 1996). Female substance abusers are particularly vulnerable to traumatic events such as sexual violence, human trafficking, domestic violence, or losing their children.

Dual Disorders: When Living With PTSD Involves Additional Psychiatric Conditions

When more than one mental health condition is present at the same time, a person has what's known as dual disorders, dual diagnosis issues, co-existing disorders, concurrent disorders, or co-occurring disorders. All of those terms have the same meaning: two disorders exist at the same time and complicate each other. People who have PTSD and an addiction are considered to have a dual disorder. Dual disorders complicate each other because they interact, exaggerate, and aggravate one another.

In the case of PTSD and addiction, many interactions occur between the two. Examples are listed below:

1. For addicted people with PTSD, drug and alcohol cravings tend to be more intense (Simpson, Stappenbeck, Varra, Moore, & Kaysen, 2012).
2. Addicted people with PTSD tend to relapse more quickly after addiction treatment than others do (Brady, Back, & Coffey, 2004).
3. When symptoms of one condition (PTSD or addiction) worsen, symptoms of the other do as well. And when one condition improves, so does the other (Brown, Stout, & Gannon-Rowley, 1998; Back, Brady, Sonne, & Verduin, 2006).
4. People tend to use more substances on days when their PTSD symptoms are worse than normal (Berenz & Coffey, 2012).
5. Symptoms of PTSD get better after substance use stops (Coffey, Schumacher, Brady, & Cotton, 2007).
6. One of the most disturbing PTSD symptoms in women who are addicted is a high rate of suicidal thinking, suicide attempts, and self-harm (Harned, Najavits & Weiss, 2006).
7. PTSD symptoms in men with addictions can include self-harm, suicidal thinking and behavior, violence against others, and HIV risk behaviors (Najavits, Schmitz, Gotthardt, & Weiss, 2005).

Anxiety, Depression, and Other Psychiatric Disorders

Both PTSD and addiction tend to occur alongside other mental health or psychiatric disorders. For example, check out the following information:

1. PTSD and Other Psychiatric Disorders
   • About 80% of people with PTSD also have at least one other psychiatric disorder (Foa, 2009).
   • The most common conditions that occur along with PTSD are depression, addiction, and anxiety disorders (Brady, Killeen, Brewerton, & Lucerini, 2000).
   • Bipolar disorder and PTSD often occur together in victims of violence (Quarantini, et al., 2009).
2. Addiction and Other Psychiatric Disorders
   • People with anxiety disorders tend to use alcohol and other drugs like benzodiazepines and sedatives to cope with their symptoms.
   • About 40% of people with alcohol problems and over half of those who have problems with other drugs report mood problems such as mania, bipolar disorder, and chronic depression. PTSD, when it occurs alongside those problems, tends to make them even more challenging to overcome.
   • People with personality disorders tend to have high rates of chronic substance abuse involving more than one substance.
   • About 50% of people diagnosed with a severe mental illness such as schizophrenia have substance problems. (Wynn, 2014)

Treatment for the Dual Disorders of Addiction and PTSD

Professionals recommend that all dual disorders be treated in an integrated way for the greatest chance of recovery. This means that treatment should be done to address both the addiction and any other mental health condition at the same time. It's possible to find dual disorder providers and treatment settings that are specifically geared toward that purpose. In some cases, one treatment provider is dually trained. In others, a whole team of providers has dual training. And, sometimes, different providers make arrangements to coordinate simultaneous treatment for both conditions. For example, an addiction specialist and a PTSD specialist would closely coordinate treatment for one person with both disorders.

Treatment Settings

Multiple kinds of settings can be used for treating the dual disorders of addiction and PTSD: residential treatment, partial hospitalization, day treatment, or inpatient or outpatient settings. Decisions about which setting is best are made on a case-by-case basis in consultation with a mental health therapist, addiction specialist, or psychiatrist. Consideration is given to several factors in making those decisions, such as:

• If there is danger to one's self or others, or if a medical detox from substances is needed, then inpatient or residential treatment is likely to be recommended. In this situation, a person stays at the treatment center to have a safe, therapeutic, and structured environment in which to start recovering from both conditions.
• If no danger exists, but a person needs time away from usual living circumstances in order to make progress, then residential treatment may be recommended until he or she makes enough improvement to return home and has a better chance to manage recovery from there.
• Day treatment and partial hospitalization provide in-between settings. They are less intensive than residential or inpatient options, but they usually allow for more therapy time than outpatient sessions do. People who participate in partial hospitalization and day treatment programs live at home, but they attend therapy for several hours or several days each week. These options are usually recommended after some progress has been made (for example, abstinence from substances or improved coping with PTSD symptoms) but when continued support for daily coping is needed.
• Outpatient treatment is the least intensive of all options. It is usually carried out in an office—on an appointment basis—for individual therapy and sometimes for group or family sessions.
• Self-help groups are often recommended. They supplement treatment and help provide support for continued recovery. For example, self-help groups, such as Alcoholics Anonymous and Narcotics Anonymous, exist for substance abuse problems. Some communities also have support groups for PTSD sufferers or those with other trauma-related issues. Many people who suffer from PTSD and alcoholism (or other forms of addiction) attend both types of groups. Support groups also exist for people with various kinds of dual disorders.

Addiction Treatment Methods

Treatment for substance problems usually involves detox from drugs or alcohol with the support of trained staff who monitor the process. Detox can take place in an outpatient setting, but it isn't always safe that way. If you are considering this option, then a thorough consultation with a physician is recommended. You should also honestly report the substances you are using, along with the amounts and frequency of their use so that you can undergo safe withdrawal from them. There are many possible complications of a poorly monitored detox. Some are life-threatening.

Depending on the setting, a plan is typically made—in consultation with a therapist, doctor, or treatment team—for learning about your addiction, the interaction between substance use and PTSD, prevention of relapse, and managing your recovery. Also, individual therapy and group therapy are significant parts of addiction recovery treatment. They can help you address issues such as coping with emotions and conflict, correcting unhelpful thought patterns and beliefs, and improving communication, problem-solving, and stress-management skills.

PTSD Treatment Methods

Several methods exist for treating PTSD. They are all intended to help improve a person's ability to function in daily life while decreasing his or her symptoms and levels of distress. Examples include:

• CBT, or Cognitive Behavioral Therapy—People learn to manage their anxiety and fear about a traumatic event by examining their beliefs about themselves, others, the world, and the event while also changing unhelpful thoughts and beliefs, gradually confronting the event in a safe and supported way, and learning to use relaxation skills and manage strong emotions (Zayfert & Becker, 2007).
• CPT, or Cognitive Processing Therapy—People work with the story of their trauma in order to feel the emotions of their experience, find different viewpoints, reduce their fears, and make better sense of what happened. They explore the impact of the trauma upon their lives and identify their symptoms, PTSD-related or otherwise. They do that by talking with therapists, doing writing exercises, using PTSD worksheets, identifying thoughts and feelings, and learning to choose the thoughts that are most helpful (Veterans Health Administration, 2012).
• Seeking Safety—This treatment method deals with both PTSD and addiction at the same time. It is designed to focus on coping in the present rather than exploring past trauma or memories of it (Najavits L. , 2002).
• EMDR, or Eye Movement Desensitization and Reprocessing—This method uses movement of the eyes or other activities to help process trauma memories so that symptoms of PTSD decrease (Shapiro, 2014).
• Exposure Therapy—Various forms of this method exist. They are designed to gradually decrease the fear and anxiety about a traumatic event. Methods may involve using actual or imagined images or reminders of the trauma. Actual exposure to things or situations that cause fear and anxiety may also be used.

Note: The treatment methods listed above are not an all-inclusive list of options for successfully treating the dual disorders of PTSD and addiction. You should consult with healthcare providers who are knowledgeable about dual disorder treatment in order to determine which methods are appropriate for you or a loved one.

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With expert help, you can regain your well-being and start creating a life that's free of the challenges caused by PTSD, alcohol abuse, drug abuse, and/or compulsive behavior.