PTSD Treatment for Substance Use Disorders

The Connection Between PTSD and Addiction

What is PTSD, and what causes PTSD?

Posttraumatic stress disorder (PTSD) is a psychiatric condition that can occur in people who have experienced or witnessed a traumatic event such as a severe accident, sexual, physical, or psychological violence, a natural disaster, or a terrorist act. PTSD can affect anyone at any age and can have significant lifelong effects.¹

What Are the Symptoms Of PTSD?

Individuals who suffer from PTDS may experience a variety of symptoms. Most symptoms of PTSD fall into one of four categories: intrusion, avoidance, alternations in thoughts and mood, and alternations in arousal and reactivity.¹

Intrusion

Flashbacks
Nightmares
Disturbing and intrusive thoughts and feelings relating to the experience

Avoidance

Avoiding talking about what happened
Avoidance of situations, people, places, and objects that may be triggering to you or remind you of the traumatic event

Alterations in Cognition and Mood

Sadness
Fear
Anger
Guilt/self-blame
Shame
Feelings of detachment from others
Inability to enjoy the activities that you previously enjoyed
Negative feelings about yourself

Alterations in Arousal and Reactivity

Negative reactions to otherwise ordinary events such as loud noises or accidentally being touched
Irritability
Angry outbursts
Reckless or self-destructive behavior
Being overly paranoid about your surroundings
Being easily started
Problems concentrating or sleeping

How Is PTSD Diagnosed?

To be diagnosed with PTSD, you had to have had exposure to an upsetting, traumatic event. This event could be both direct or indirect. For example, you could also develop PTSD from learning about a close family member or friends’ violent death versus having had that experience yourself.¹ Another example is the repeated exposure of violent details of trauma, such as police officers or social workers being exposed to excruciating details of child abuse. PTSD can also occur over time and doesn’t necessarily manifest as the reaction of one particular incident.¹

DSM-5

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th Edition outlines the following criteria for a PTSD diagnosis.²

Criterion A: Stressor (one required)

The individual was exposed to: actual or threatened death, injury, sexual violence through:

Direct exposure
Witnessing trauma
Learning that a relative or close friend was exposed to trauma
Indirect exposure to details of trauma (typically in the course of professional duties such as paramedics or police officers)

Criterion B: Intrusion Symptoms (one required)

The traumatic event is repeatedly re-experienced in the following way(s):

Unwanted upsetting memories
Nightmares
Flashbacks
Emotional distress after exposure to traumatic reminders
Physical reactivity after exposure to traumatic reminders

Criterion C: Avoidance (one required)

Avoidance of trauma-related stimuli after the trauma, in the following way(s):

Trauma-related thoughts or feelings
Trauma-related external reminders

Criterion D: Negative Alterations In Cognitions And Mood (two required)

Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):

Inability to recall important details of the trauma
Overly negative thoughts and assumptions about yourself or the world
Exaggerated blame of self or others for causing the trauma
Negative affect
Decreased interest in activities
Feelings of isolation
Difficulty experiencing positive affect

Criterion E: Alterations In Arousal And Reactivity (two required)

Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

Irritability or aggression
Risky or destructive behavior
Hypervigilance
Heightened startle reaction
Difficulty concentrating
Difficulty sleeping

Criterion F: Duration (required)

Criterion G: Functional Significance (required)

Symptoms create distress or functional impairment (e.g., social, occupational).

Criterion H: Exclusion (required)

Symptoms are not due to medication, substance use, or other illness.

ICD-10

The International Classification of Diseases Tenth Revision provides a similar set of criteria for diagnosis. They are:³

Exposure to a stressful event or situation
Persistent remembering or re-living of the stressor in flashbacks, nightmares, etc.
Avoidance of triggers associated with the stressor or trauma
Either of the following is present:
Inability to recall key details of stressor
Persistent symptoms of increased psychological sensitivity and arousal shown by any of the following two:
Difficulty falling/staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Exaggerated startle response
Criteria B, C, and D must all be met within 6 months of the traumatic event (in some cases, delayed onset may be included).

Trauma and Substance Use Disorder

Trauma and substance abuse often go hand in hand. This connection is because trauma that is left untreated can often cause individuals to turn to substances to cope with the symptoms of trauma. Alcohol and substances can help reduce physiological arousal, increase disinhibition and provide cognitive distractions that help mitigate the symptoms of PTSD.⁴ The downfall of this is that substance abuse can quickly make PTSD worse if both disorders are left untreated.⁴

PTSD and Addiction Statistics

According to the American Psychiatric Association, PTSD affects about 3.5% of adults in the U.S. every year.¹ Approximately one in 11 people will be diagnosed with PTSD in their lifetime. Women are twice as likely as men to be diagnosed with PTSD.¹ According to a national study, approximately 46% of individuals with a PTSD diagnosis also met the diagnostic criteria for a substance use disorder.⁵

Veterans with PTSD are approximately three times more likely than veterans without PTSD to develop a substance use disorder. For most individuals, PTSD tends to occur before a substance use disorder because many individuals use substances to self-medicate to help with PTSD symptoms.

How is PTSD Treated During Substance Use Disorder Treatment?

Individuals with both PTSD and a substance use disorder benefit the most from a trauma-focused, cognitive behavioral therapy such as CBT, EMDR, or Prolonged Exposure Therapy.⁵ Studies have shown that people with a dual diagnosis of PTSD and substance use disorder had lower PTSD symptoms when they received psychotherapy than people who received treatment that was only focused on treating the substance use disorder. Trauma-focused treatment also lowers the risk of relapse because the trauma is often the reason for the substance abuse issue. PTSD treatment can often help individuals address the root causes of their addiction and try to find coping strategies to work through PTSD and substance abuse. Some forms of treatment that are beneficial for managing PTSD and substance abuse are:

Eye Movement Desensitization and Reprocessing Therapy

Eye Movement Desensitization and Reprocessing Therapy (EMDR) is a newer and non-traditional form of psychotherapy. EMDR uses rapid, rhythmic eye movements to recall the memories of traumatic events.

EMDR sessions can last up to 90 minutes, during which your therapist will move their fingers back and forth in front of your face and have you follow the motion with your eyes. Simultaneously, you will be asked to recall a traumatic event. Your therapist will then shift your focus to more peasant events and thoughts. The idea is that remembering the events while moving your eyes from side to side will help lessen the distress surrounding the event and decrease the event’s emotional impact. This action lowers stress because you are likely to be less emotionally distressed when you are distracted and your attention is split.

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) is one of the more well-known forms of therapy used in PTSD treatment and the treatment of substance abuse disorders. It was founded by Dr. Aaron Beck in the 1960s and focuses on tackling problematic thoughts and feelings surrounding whatever issues you may be dealing with, such as PTSD. CBT focuses on showing how your thoughts and feelings may be irrational and illogical and may stem from past experiences or traumas rather than being rooted in reality or facts. Once you understand why you feel or behave a certain way and how a traumatic event impacted you, you are better equipped to overcome substance abuse.

Prolonged Exposure Therapy

Prolonged Exposure Therapy is a type of cognitive-behavioral therapy that is specific to treating trauma. The idea behind prolonged exposure therapy is that individuals with PTSD tend to avoid anything that might remind them of their trauma, reinforcing the fear and negative feelings surrounding the trauma.⁶ During prolonged exposure therapy, you gradually approach memories, feelings, and trauma-related situations, allowing them to understand that the memories and feelings are not dangerous and do not need to be feared. Over time, the hope is that being exposed to the triggers will help you not react so strongly to trauma triggers. Prolonged exposure typically occurs over about three months with weekly sessions.⁶

PTSD Medication

In some cases, medication may be necessary to help treat PTSD and allow successful psychotherapy. Medications used for PTSD are antidepressants such as SSRIs and SNRIs. The four medications typically used to treat symptoms of PTSD are: sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and venlafaxine (Effexor).⁷

PTSD vs. Acute Stress Disorder

Acute stress disorder (ASD) refers to the immediate onset of symptoms experienced after a stressful event that typically lasts up to a month. PTSD, on the other hand, refers to the long-term symptoms that can occur gradually after experiencing or being exposed to a traumatic event or traumatic details. PTSD symptoms can take months or years to develop and can last for years if left untreated. While acute stress disorder can sometimes be the precursor to PTSD, that is not always the case. While both acute stress disorder and PTSD symptoms are similar, individuals with ASD typically experience more dissociative symptoms.

PTSD and Relapse

Medical professionals used to believe that PTSD therapy might cause a relapse in people with substance use disorders. They feared that bringing up and talking about emotional and psychological trauma could cause someone to feel stress again and want to use substances to combat those feelings. Recent studies have shown that this is not the case and that PTSD treatment does not cause a relapse. On the contrary, receiving treatment for both PTSD and substance abuse disorder has proven to improve treatment outcomes and reduce the chances of relapse because it is easier to target the cause of the issues.