Addiction and Post-Traumatic Stress Disorder

Approximately 50% – 66% of people who suffer from post-traumatic stress disorder (PTSD) also struggle simultaneously with addiction (and vice versa). People with PTSD or any form of anxiety disorder are also two to four times more likely to develop a substance abuse problem than their peers.

According to the National Institute of Mental Health (NIMH), PTSD is a disorder that will affect 7- 8% of people during their lifetime.

Chronic stress can interfere with a person’s impulse control, cognition and memory functions. One way PTSD sufferers cope with the disorder is to use drugs as a method of self-medication from symptoms and stress. However, regular drug use impacts the same parts of the brain that high levels of stress can.

With repeated drug use, it will become more difficult for the brain to continuously regulate amounts of dopamine, adrenaline and GABA, as it normally should. Soon, the drug user’s brain will no longer be able to function independently of the addictive substance; this is known as dependence. As dependence sets in, drug cravings and uncomfortable withdrawal symptoms such as depression, anxiety, irritability and insomnia make it harder to quit.

Substance-related PTSD can be treated with the right medication, psychotherapy and support. If you need help or know someone who does, speak with a professional immediately.

What is post-traumatic stress disorder?

To further understand the relationship between PTSD and addiction, it is important to know what PTSD is and how it affects a person’s mental health.

PTSD can occur following the experience of a traumatic or life-threatening encounter. When someone is in danger, the brain activates the ‘flight or fight’ response. This alters the brain chemicals, blood pressure, heart rate, respiration and body temperature. Attention and focus levels are increased and there is an adrenaline surge.

This keeps the individual alert and wide awake, so that they can escape the potentially dangerous situation – it is a natural response to danger. However, when the stress response continues to occur long after the danger has passed – even when the body has no need to protect itself from harm – that person may have post-traumatic stress disorder.

In some cases, symptoms of PTSD may manifest months or even several years after the traumatic event. Examples of situations that may cause PTSD include motor accidents, being a victim of crime, the death of a close friend or witnessing to a fatal accident or life-threatening event. Even surviving a natural disaster such as a hurricane can trigger PTSD symptoms.

A diagnosis of PTSD may be made by a professional if symptoms persist and start interfering with the individual’s life, preventing them from performing their regular activities.

Spotting Addiction and post-traumatic stress disorder

People with PTSD may rely on drugs to avoid memories, numb certain emotions or to fall asleep.

In a normal stress response, the hypothalamic-pituitary adrenal (HPA) axis is activated, including the hippocampus, amygdala and prefrontal cortex of the brain. The stress causes these centres to release norepinephrine and cortisol, which increase arousal and help us avoid the danger.

Unfortunately, people with PTSD tend to suffer stress that triggers this reaction continuously, causing them to feel anxiety on a regular basis. To calm themselves, many sufferers use drugs such as marijuana or anti-anxiety medication such as benzodiazepines (e.g. Lorazepam, Ativan, Xanax).

These drugs are addictive and affect dopamine levels in the brain. If continuously abused, this can lead to addiction. The chances of drug-dependence are always high amongst people with PTSD. By spotting the signs early, you can begin treatment or get someone the help they need.

Signs and symptoms can be broken down into two categories: signs of PTSD and signs of addiction:

Signs of PTSD

Behavioural changes can include increased conflict with others, low self-esteem, poor performance at work and neglect of responsibilities or activities they used to enjoy. Eventually, they resort to drugs as a coping mechanism. When people with PTSD abuse drugs, you will observe certain distinctive signs.

Signs of addiction (substance abuse)

• Using more than their recommended prescription or seeking illegal drugs such as cannabis
• Finding it hard to quit
• Experiencing strong cravings for the drug
• Allowing fixation on the drug to affect their performance at home, school or work
• Using the substance continuously, despite the problems it causes
• Letting go of hobbies or favourite activities in favour of substance abuse
• Persistent use of the substance, despite physical and psychological consequences

If you or a loved one exhibits any of these signs (including experiencing withdrawal symptoms when you try to quit), then you should see an addiction specialist. Recovery is easier when you address the issue early on.

Origins of post-traumatic stress disorder and who is at risk

Other heroes and heroines in popular literature have also experienced their fair share of traumatic encounters.

There is substantial evidence that PTSD susceptibility might be hereditary. Roughly 30% of the variance to PTSD has been traced to genetics alone. For example, monozygotic (identical) twins who were exposed to combat in Vietnam were discovered to be at increased risk of having PTSD if one of them had it, unlike dizygotic (non-identical) twin pairs.

There is also evidence that people with a genetically smaller hippocampus are more likely to develop PTSD after a traumatic encounter. Studies have also shown that PTSD has several genetic influences common to other mental health disorders. For example, panic disorder, generalised anxiety disorder (GAD) and PTSD share 60% of the same genetic variance. Meanwhile, nicotine, alcohol and drug dependence share more than 40% genetic matches.

Based on the trauma concept of PTSD, other people considered to be at risk of the condition include combat military officers, concentration camp survivors, victims of natural disasters and victims or witnesses of violent crimes.

If you’re exposed to violent situations in the workplace, you could be at risk too. For instance, people who work as first-responders to emergencies (such as army doctors, paramedics and fire fighters) should be tested regularly for symptoms of PTSD. Other occupations at risk include police officers, healthcare experts, journalists, deep sea divers, bank workers and so on.

Childhood trauma and victims of sexual abuse, domestic violence, life-threatening sickness and pregnancy trauma are also at risk of developing PTSD. It is believed that women are twice as likely to develop post-traumatic stress disorder than men.

Symptoms of post-traumatic stress disorder

PTSD has many symptoms, which tend to manifest in several different ways. Experiences vary between individuals. While some have fearful flashback experiences, others struggle with more depressive moods, negative thoughts and social anxiety.

The symptoms of PTSD can be divided into three major categories:

1. Intrusion (re-experiencing the traumatic incident)
2. Avoiding experiences that trigger memories of the trauma
3. Hyper-arousal symptoms

People who experience these symptoms for at least a month may be diagnosed with PTSD. The following provides a detailed description of each category.

Intrusion

Avoidance

• During this stage, patients avoid external factors surrounding the event such as locations, related discussions and people and activities associated with the event
• They will also try to avoid fearful thoughts, feelings and memories associated with the event

Hyper-arousal symptoms

Hyper arousal is characterised by the inability to stay calm. You will notice heightened physical behaviour such as restlessness and panic. Other signs include:

Negative mood and thought changes

The individual will tend to think more negatively. PTSD triggers behaviours that looks like generalised anxiety disorder (GAD), such as:

Before you receive a formal diagnosis for PTSD, you must have displayed at least one of the intrusion symptoms, one avoidance symptom, two hyperactive symptoms and at least two of the negative mood and thought changes for over a month.

Post-traumatic stress disorder and addiction: Understanding the relationship

Research reveals that while about 70% of the population may encounter a traumatic event in their lifetime, only 8% will go on to develop PTSD. The perception of helplessness in the face of trauma is the key to developing PTSD. For instance, with a child in who is being abused, the greater the feeling of helplessness, the more likely they are to become trapped in the hyperarousal cycle and develop PTSD later.

When we encounter danger, our sympathetic system responds and triggers the adrenal system, which releases cortisol that prepares us to face (fight) or escape (flight) the danger. Some people even freeze in certain situations. When the danger is gone, our body relaxes and calm is restored to the central nervous system (CNS).

Unfortunately, not everybody recovers completely from a traumatic experience. Some people still feel the stress of the event as if it were happening again – even several months or years later. This constant state of agitation leads them to find solace in CNS-depressant medication or anti-anxiety pills.

When alcohol or drugs are used to cope with the effects of PTSD, symptoms only worsen. Because they are CNS depressants, alcohol and opiates exacerbate anxiety and depression and interfere with regular sleep patterns.

It is easy to assume that treating the trauma will stop you from abusing the substance, but the addiction may persist, given that the reward pathway in the brain has been ‘hijacked’. The result is the development of tolerance and the urge to continue seeking the drug (dependence), to prevent uncomfortable withdrawal symptoms.

According to a study by the National Comorbidity Survey (published in 1995), 52% of men and 28% of females with PTSD meet the lifetime criteria for alcohol dependence or abuse. For drug abuse, the same survey showed 35% men and 27% women respectively.

Endorphin withdrawal is essential in the use of drugs or alcohol as a coping mechanism for PTSD. When the body experiences a significant traumatic event, the brain releases endorphins, a class of neurotransmitters that reduce pain and produce a feeling of well-being to cope with stressful situations.

When the stressful event is over, the body suffers a lack of endorphins, which in turn produces similar symptoms to drug or alcohol withdrawal:

According to Alcohol Research and Health, many people with PTSD will turn to alcohol (or drugs) to fill the gap produced by the brain’s lack of endorphins. However, the pleasant effects are only fleeting. Taking the substance continuously leads to abuse, until the brain is unable to function fully without it. The physical (or psychological) discomfort experienced through withdrawal indicates the formation of addiction.

Besides endorphins, other neurotransmitters involved in the body’s PTSD, substance abuse and addiction relationship include dopamine, serotonin and Gamma Amino Butyric Acid (GABA).

Therefore, it is important to consider this relationship or dual-diagnosis during treatment for addiction and PTSD. Treating one without regard for the other could undermine the whole procedure and thwart recovery.

Why are so many people with post-traumatic stress disorder addicted to substances?

The main reason is that people with this disorder are seeking escape from the stress or memory of their trauma. Substance abuse, PTSD and addiction all have a complex relationship that can make treatment difficult.

High stress levels make it more likely for a person to seek relief with alcohol or drug use. These substances can stimulate pleasure, reduce anxiety and provide distraction from unpleasant emotions.

When you are stressed, the GABA levels in your body decrease and adrenaline is increased. GABA acts as the body’s natural tranquiliser and is produced by the brain. Certain drugs like marijuana, alcohol, opiates and benzodiazepines can stimulate the production of GABA and depress CNS. These drugs also increase the levels of dopamine in the brain. Dopamine is described as the ‘happy hormone’, as it creates a false feeling of ‘euphoria’.

When the effect on the body wears off, you’ll feel a drop in your mood because dopamine levels will also drop. With repeated drug abuse, it will become more and more difficult for the brain to continue regulating levels of adrenaline, dopamine and GABA normally.

As dependence forms, the cravings and painful withdrawal make it even harder for someone with PTSD to stop using drugs or abusing alcohol. Eventually, the individual may lose control over their hold on the substance.

Young brains (children aged 10 to 17) that are not fully developed may be more susceptible to PTSD if they experience any trauma during this period. Trauma means they’re also more likely to become substance abusers when they get older. PTSD and addiction are like both sides of a coin. Subsequently, genetics, a stressful environment and biology can all play a part in the development of both disorders.

At first, the drug may appear to provide some relief, but this is only temporary. The mind of the PTSD patient is often crowded with thoughts of negativity, fear and anxiety. This hyperactivity sends electrical charges to the prefrontal cortex and other parts of the brain.

When you use a CNS depressant such as Ativan, it binds with the GABA receptors in the brain to stimulate production of Gamma Amino Butyric Acid (GABA). The secretion of GABA relaxes the overexcited parts of the brain because it functions as a natural calmative. Dopamine levels are also increased, and the result is a mild feeling of euphoria. This temporary relief acts as a positive reinforcement and the hippocampus registers it for future purposes.

When the drug wears out, dopamine levels fall, and feelings of depression and anxiety return. To avoid this, the person with PTSD will continue taking Ativan to the point of dependence. It is difficult to quit without help at this point, because of the withdrawal symptoms.

Ironically, one of the symptoms of Ativan withdrawal is the rebound of anxiety – the initial ailment for which the drug was meant to cure. Unless treatment is managed by a professional, the discomfort of withdrawal may drive the patient to relapse. For treatment of co-morbid disorders, both addiction and PTSD must be addressed separately.

Living with post-traumatic stress disorder and addiction

There are better ways to cope with PTSD than relying on drugs or alcohol. If you are currently suffering from both disorders, see a professional therapist for treatment. You could also help a friend or relative who is struggling with the condition.

In the meantime, there are activities that can help you take your mind of the stress of PTSD.

Risks associated with long-term addiction and post-traumatic stress disorder

The best time to treat an addiction is now. Leaving it to fester for a long period makes it even more difficult to treat. The risks associated with withdrawal stem from long-term untreated addiction.

Treatment for long-term addiction is possible, but takes longer and requires more effort. The physical symptoms are more severe, and without proper support or supervision, complications may arise. For instance, if not properly managed, uncontrollable seizures and convulsions can cause coma.

Another risk of long-term addiction is the tendency to relapse and overdose. This is more common among those who try to quit ‘cold turkey’. The discomfort of withdrawal may be so severe that in their desperation to seek relief, the individual could overdose.

One of the symptoms of withdrawal is rebound-PTSD. If your addiction is long-term, the discomfort will be severe. Unless a qualified doctor is around, rebound PTSD could bring about complications.

Post-traumatic stress disorder and alcohol addiction

One of the common ways people cope with PTSD is by drinking. The safe drinking level is one or two units per day. However, people with PTSD tend to drink more to numb anxiety. It is never a good idea to find relief in substance abuse, as it only worsens the condition.

With PTSD, you have a mental health disorder that is easier to treat, but alcohol addiction adds to the complication by introducing dual diagnostic problems. One of them is Delirium Tremens, an alcohol withdrawal symptom that triggers hallucinations and worsens PTSD.

Alcohol can worsen PTSD, as it has its own withdrawal that makes it more complicated to treat. Many patients spend three to four months in rehab, until they stop experiencing withdrawal.

Risks of using alcohol to cope with post-traumatic stress disorder

The following risks are common when using alcohol as a PTSD coping mechanism:

Integrated treatment for dual diagnosis of post-traumatic stress disorder and substance abuse

If you know somebody with PTSD who is also alcohol-dependent, look for a physician who specialises in dual diagnosis. They are experienced at treating both conditions, without compromising the patient’s chances of full recovery.

The first step will require tapering from alcohol. During this time, they will prepare the body for withdrawal. Once detox begins, the physician will be ready to deal with both symptoms of alcohol withdrawal and PTSD-rebound symptoms, because they must both be addressed. It won’t be easy but with the right therapy and support, the patient can recover from their addiction.

An inpatient rehabilitation programme is the best option for dual-diagnostic conditions. Many patients spend up to 90 days or longer as an inpatient, for a more comprehensive treatment. During this time, they will receive behavioural therapy and mental orientation that changes the way they perceive alcohol. The objective is to live independently of alcohol whilst learning natural coping mechanisms to manage the symptoms of PTSD.

Common therapeutic solutions include:

Some medications may be used to mimic the effect of alcohol on the CNS receptors and suppress cravings. However, it is important to use non-addictive drugs to avoid substituting one addiction for another. Other non-medical solutions include alternative practices like meditation, yoga and Reiki.

Choosing the best dual diagnosis treatment centres for post-traumatic stress disorder and addiction

Your recovery is only as effective as the type of facility you choose. When selecting a place for treatment, ensure you pick one that not only specialises in dual diagnosis, but is fully equipped to meet your personal needs and preferences.

Frequently Asked Questions

Sources

• https://americanaddictioncenters.org/ptsd/
• https://www.ptsd.va.gov/professional/newsletters/research-quarterly/v7n4.pdf