Post-Traumatic Stress Disorder and Addiction


After experiencing or witnessing any terrifying event, such as a natural disaster, military combat, or a car accident, the mind and body need time to recover from the shock and regain a sense of stability. However, some people who survive a traumatic experience may be slower to recover or may carry lasting consequences of the experience for an indefinite amount of time. Instead, they are left with distressing memories, flashbacks, and strong emotions such as helplessness, fear, anger, and intense anxiety regarding the incident. Sometimes, these symptoms may be so overwhelming and intrusive that they predominate the individual’s thoughts and interfere with daily activities. In some instances, these individuals may turn to drugs or alcohol in an attempt to manage their fears or flashback. However, in doing so, they may only worsen their issues.

The condition known as post-traumatic stress disorder (PTSD) has been estimated to affect about 7 or 8 out of every 100 people in the U.S. at some point in their lives. As many as 8 million people in the United States in any given year may struggle with PTSD, according to the U.S. Department of Veteran Affairs.1 Military members, first responders, civil servants, and other individuals more likely to face violence or injury may be at particular risk; however, PTSD can affect anyone who has experienced or witnessed a traumatic incident.

PTSD can be quite debilitating, but the condition is treatable. By identifying the problem and seeking support, many have become better able to manage the intrusive thoughts, flashbacks, and other forms of psychological distress that often characterize PTSD.

What Is Post-Traumatic Stress Disorder?

Post-traumatic stress disorder is a diagnosable mental health condition whose characteristic feature is the development of certain types of symptoms following exposure to a traumatic event(s), though the presentation of these symptoms may vary from one individual to the next.2 For example, emotional and behavioral symptoms—including fearful re-experiencing of the traumatic event—may predominate with some people, while others may be primarily troubled by negative thoughts and changes in mood. Still, others may experience hyperarousal or dissociative symptoms, or some combination of all of the above.2,3 In some cases, these symptoms may be intrusive and significantly distressing; such recurrent experiences can negatively impact a person’s life and ability to function on the job, at home, and in relationships with other people.

Caused by experiencing or witnessing a life-threatening event (e.g., terrorist attack, physical or sexual assault, natural disaster, war experiences, etc.), a person may be unable to process the event and function without a range of symptoms triggered by memories of the experience.

Risks and Protective Factors for PTSD

Why do some people develop PTSD after trauma, while others live through shocking or frightening experiences without pervasive repercussions? Certain risk factors may make it more likely that an individual develops PTSD; conversely, resilience factors may help to reduce the risk.4 For example, direct exposure to trauma or injury may increase an individual’s risk; additional risk factors include having little or no social support surrounding the triggering event, having to grapple with extra stresses associated with the event (such as pain and injury or loss of a loved one), and having a history of substance use or other mental health issue(s).1,4 Other risks include female gender, lower socioeconomic status, childhood adversity, childhood emotional problems, and being of younger age at the time of the trauma.2

On the other hand, some factors may promote recovery after living through a traumatic experience. Such protective, or resilience, factors include the availability of and seeking out of support from friends and family or other supportive groups, having a positive coping strategy to better navigate and learn from the traumatic event, and having the capacity to act and respond effectively in the face of the fear associated with the trauma.4

How Is PTSD Diagnosed?

Clinicians make PTSD diagnoses based on the presence of several characteristic symptoms. The National Institute of Mental Health (NIMH) indicates that the diagnostic symptoms must be present for at least one month in adults receiving a diagnosis of PTSD. These include the following:2,4

At least one avoidance symptom:

  • Avoiding conversations, situations, people, or other things that might trigger memories of the traumatic event
  • Altogether avoiding trauma-related thoughts and feelings

In some cases, attempts at avoidance result in changes to personal routines, such as not driving or riding in cars after an automobile accident. Other times, distraction techniques may begin to be used to avoid such reminders.

At least one re-experiencing symptom:

  • Flashbacks or a repeated reliving of the trauma, which may elicit physical symptoms such as sweating or racing pulse
  • Nightmares or frightening waking thoughts

At least two hyperarousal symptoms:

  • Feeling edgy, tense, or hyperaware of potential threats
  • Feeling jumpy
  • Having a hard time falling asleep or staying asleep
  • Reacting angrily, often unexpectedly or to objectively small stimuli

Arousal symptoms are often constant, instead of being triggered. They can interfere with concentration and with daily tasks such as sleeping and eating.

At least two cognition/mood symptoms:

  • Negative outlook about oneself or the world
  • Distorted feelings about guilt and blame
  • Difficulty remembering key elements of the trauma
  • Loss of interest in previously enjoyed activities

People who struggle with post-traumatic stress disorder may be so impacted by the event or events that they feel uncomfortable, unhappy, on edge, and/or disconnected most of the time. They may find it difficult to manage simple tasks without unexpectedly rearranging their daily routine in an attempt to mitigate their symptoms. Many struggle with relationships with others, their ability to remain employed, their sense of self and purpose, and substance abuse as a result of the disorder.

Who Is Affected by PTSD?

As mentioned earlier, previous estimates point to a lifetime prevalence for PTSD in the U.S. between 7 and 8 percent of the population—meaning that roughly 7-8% of all people in the U.S. may develop PTSD at some point in their lifetime.1 Looking at previous past year estimates, PTSD has affected about 3.6% of the adult population in the U.S.—or roughly 9 million people per year.5,6 This number represents only a small percentage of those who have survived a trauma, but for those who live with this condition, the impact on their lives can be enormous.

Anyone who has been directly or indirectly affected by a traumatic event may experience PTSD. Some of the experiences that can lead to this disorder include:

  • Robbery
  • Sexual assault
  • Physical assault
  • Child abuse
  • Motor vehicle accidents
  • Homicide
  • Natural disasters
  • Terrorist activity

The time of onset for PTSD symptoms is variable—in many cases, the triggering incident may have occurred relatively recently (e.g., within the past 3 months), though there may be a delay of several months to years before a person exhibits the diagnostic symptoms of the disorder.2,4 The course of the condition also varies from one person to the next. For example, some recover within 6 months, while others experience chronic PTSD-related issues.4

PTSD in Military Members

While lifetime PTSD estimates of 7-8% were made for the general population, the U.S. Department of Veterans Affairs estimates that 11-20% of Operations Iraqi Freedom and Enduring Freedom Veterans have PTSD in a given year.7,8 Similarly, about 12% of veterans who served in the Gulf War struggle with PTSD in a given year. About 30 percent of veterans who served in the Vietnam War are believed to have lived with PTSD at some point in their lives.7,8

 

Substance Use Disorder and PTSD

Research evidence supports a link between substance use disorder (SUD) and PTSD and substance abuse. Across various studies, the prevalence of current PTSD in patients with SUD may be as high as three times greater than that seen in the general population.9

The results of the National Comorbidity Survey (or NCS, a large-scale epidemiological study conducted in the 1990s) suggested that people with PTSD were, relative to those without PTSD, as much as 4 times more likely to additionally meet criteria for a substance use disorder.3

People who have experienced physical or emotional trauma may be at higher risk of substance use—whether it be alcohol or other licit substances, prescription drug misuse, or illicit substance use.11 The link between trauma and substances may be particularly relevant to returning veterans, since as many as 1 in 5 service members back from Afghanistan or Iraq have reported symptoms of PTSD or major depression, and as many as half of all vets diagnosed with PTSD have a co-occurring SUD.11

Comorbid, or dually diagnosed PTSD and SUD, is associated with a more costly and complicated clinical course (e.g., worse long-term health, poorer social functioning, increased suicidality, more legal issues, decreased treatment adherence, and less improvement seen throughout treatment) than either condition on its own.10 Given such issues, and the high incidence of comorbidity between the two conditions, the American Society for Addiction Medicine supports the screening for and integrated treatment of both conditions in those who initially present for treatment of either individual condition.3

Are Drugs, Alcohol, and PTSD Interrelated?

Much attention has been paid to why PTSD and substance use disorders co-occur so frequently. Perhaps the most widely proposed theory to characterize this comorbidity is that of self-medication. Proponents of this link argue that substance use may be an attempt at alleviating some of the otherwise life-disrupting symptoms of PTSD.3,10

For people whose SUD predates their issues with PTSD, several other theories point to causal links that could potentially increase their risk of ultimately developing PTSD. One such theory hypothesizes that factors such as the impaired decision making and temporarily decreased fear response that may be consistently present in people who use substances may find them in situations where they may be more likely to experience a traumatic event and subsequently develop PTSD.3 A second such theory involves the increased anxiety and arousal that commonly accompanies chronic substance use and how, in addition to diminished coping skills, they may confer a biological vulnerability to developing PTSD after a traumatic exposure.3,10

Veterans, PTSD, and Substance Use

More than 2 out of 10 Veterans with PTSD have a concurrent substance use disorder.14 As with other substances, PTSD is also associated with alcohol use problems. Just experiencing a trauma, regardless of whether or not PTSD develops, may be associated with problematic drinking. The U.S. Department of Veterans Affairs states that as many as 1/3 of those who live through traumatic illnesses, accidents, or disasters report drinking problems. 13

Roughly 10% of Veterans from the wars in Afghanistan and Iraq have a problem with alcohol or other drugs.14 The VA also reports that 60-80% of Vietnam Veterans seeking PTSD treatment have alcohol use problems and that, furthermore, war veterans with PTSD and alcohol issues commonly binge drink.13,14 Alcohol and other substance use can make the symptoms of PTSD worse and can exacerbate related issues such as sleep problems, depression, anger, and irritability.14

Treating PTSD and Addiction

Though historically, some PTSD treatment programs may not have accepted individuals with active SUDs, and some traditional SUD clinics may have deferred treatment of trauma-related issues, it is becoming increasingly recognized that there is value to implementing a simultaneous treatment strategy to best manage cases of comorbid PTSD and SUD.11

Though individual courses of treatment will vary, such an integrated treatment approach might include various behavioral and psychosocial techniques (e.g., exposure therapy) as well as applicable pharmacologic interventions.11,12

Some aspects of effective treatment may include:4,10,11,12

  • Psychotherapy or “talk therapy”: Whether in a group or 1-on-1 setting with a therapist, various forms of talk therapy may be conducted for as much as 12 weeks (or longer, as necessary).
  • Cognitive Behavioral Therapy (CBT) and Cognitive Processing Therapy (CPT): Learning how to reframe the triggering event and/or feelings caused by it through talk therapy or cognitive restructuring can help people learn how to move forward and manage previously uncontrollable reactions.
  • Prolonged Exposure (PE) therapy: A type of behavioral therapy, exposure therapy seeks to help people gradually revisit trauma-related memories and feelings that have been previously avoided. By confronting these (for example, by retelling, drawing, writing, and going to the location of the event with the goal of regaining control over the fear and stress caused by the memory), PTSD symptoms may improve.
  • Eye Movement Desensitization and Reprocessing (EMDR): Helps people process distressing trauma-related thoughts, feelings, and memories through a series of therapist-led sessions.
  • Stress management skills: Learning how to lower overall levels of stress and use anxiety-reduction techniques can help people to better recognize symptom triggers and manage their stressful reactions to them.
  • Medication: Antidepressant medications may help some people with PTSD control certain symptoms such as anger, sadness, or worry. Still, other medications may be utilized for symptomatic management for issues such as sleep disturbances.

Could Seeking Treatment Negatively Impact My Career?

It is almost certain that, historically, many in the military or in careers such as first responders may have avoided seeking support and assistance for PTSD to potentially avoid any stigma and prejudice as well as discrimination due to ignorance about these conditions.

Great efforts are being made in not only making sure that first responders and military who suffer from PTSD symptoms understand the nature of what they are experiencing and why, and have access to treatment, but also that others fully understand the nature of the disorder and that treatment can help people living with the disorder to manage their symptoms and be fully functional at work. Increased education efforts in the community and in the workplace, and increased access to treatment, can serve to decrease stigma and encourage those who would benefit from treatment to get the help they need.

Health is a Priority

Regardless of concerns about seeking treatment, one thing is undeniable: Avoiding treatment when it is necessary may only prolong one’s struggle with post-traumatic stress disorder and addiction.

Additional Resources on PTSD and Addiction

  • Anxiety and Depression Association of America: Post-traumatic Stress Disorder: This website offers screening tools, informational articles and videos, and an online coaching service for people suffering from PTSD.
  • National Center for PTSDThis division of the U.S. Department of Veterans Affairs offers information, resources, and access to support services on PTSD and substance abuse. The site focuses on the needs of military members and their families, but it is also a valuable source of help and information for civilians and their loved ones.
  • National Institute of Mental Health: PTSDThis online guide to PTSD provides education on the condition and information about support services, as well as an overview of available treatments.
  • Sidran Traumatic Stress InstituteThe Sidran Institute is an international, nonprofit organization dedicated to providing education and support for people suffering from PTSD, dissociative disorders, and other trauma-related conditions.
  • Veterans Crisis Line: This free hotline, operated by the Department of Veterans Affairs, offers confidential support and help to veterans in crisis or their families. Support is available 24 hours a day, 365 days a year, by telephone, text, or online chat.

Resources

  1. U.S. Department of Veterans Affairs—National Center for PTSD. (n.d.) How Common is PTSD in Adults?
  2. Diagnostic and statistical manual of mental disorders: DSM-5 (5th). (2013). Washington, D.C.: American Psychiatric Association.
  3. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
  4. National Institute of Mental Health. (2019). Post-Traumatic Stress Disorder.
  5. National Institute of Mental Health. (2017). Post-Traumatic Stress Disorder (PTSD) Statistics.
  6. National Alliance on Mental Illness. (2017). Posttraumatic Stress Disorder.
  7. U.S. Department of Veterans Affairs—National Center for PTSD. (n.d.). Epidemiology of PTSD.
  8. U.S. Department of Veterans Affairs—National Center for PTSD. (n.d.). How Common is PTSD in Veterans?
  9. Gielen, N., Havermans, R. C., Tekelenburg, M., & Jansen, A. (2012). Prevalence of post-traumatic stress disorder among patients with substance use disorder: it is higher than clinicians think it is. European journal of psychotraumatology, 2012;3.
  10. McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic Stress Disorder and Co-Occurring Substance Use Disorders: Advances in Assessment and Treatment. Clinical Psychology: A Publication of the Division of Clinical Psychology of the American Psychological Association19(3),
  11. National Institute on Drug Abuse. (2010). Comorbidity: Addiction and Other Mental Illnesses.
  12. Berenz, E. C., & Coffey, S. F. (2012). Treatment of Co-occurring Posttraumatic Stress Disorder and Substance Use Disorders. Current Psychiatry Reports14(5), 469–477.
  13. U.S. Department of Veterans Affairs. (n.d.). PTSD and Problems with Alcohol Use.
  14. U.S. Department of Veterans Affairs. (n.d.). PTSD and Substance Abuse in Veterans.


About The Contributor

Scot Thomas, M.D.
Scot Thomas, M.D.

Senior Medical Editor, American Addiction Centers

Dr. Thomas received his medical degree from the University of California, San Diego School of Medicine. During his medical studies, Dr. Thomas saw firsthand the multitude of lives impacted by struggles with substance abuse and addiction, motivating... Read More


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