By Krista Pine, MD, Psychiatrist, Virginia, Pinnacle Treatment Centers; Dr. Pine is board certified in both psychiatry and addiction medicine
What is Complex Post-Traumatic Stress Disorder?
Addiction treatment has come a long way in the past twenty years. If you regularly read articles about addiction treatment – or you’ve been in treatment yourself – you know we’ve moved away from using the word addiction. Instead, we’re more specific. If someone is addicted to alcohol, we now say they have alcohol use disorder (AUD). Or, we say they’ve received a diagnosis for AUD. If someone is addicted to opiates, we say they have opioid use disorder (OUD). Or, we say they’ve received a diagnosis for OUD. For drug addiction overall, we now say substance use disorder (SUD), and we refer to a person addicted to substances as a person with SUD.
Another area where we’ve made substantial progress over the past twenty years is in the treatment of mental illness, which is directly related to AUD/SUD treatment. We’ve expanded our understanding of mental health disorders – our preferred terminology in the 21st century – and updated our approach to treating people with mental health disorders such as anxiety, depression, and others. The common ground we see in the progress we’ve made in treating substance use disorders and mental health disorders is that in both cases, we now see them as medical conditions. In other words, our current understanding of both is informed by the medical model or disease model of mental health and/or addiction.
There’s another important commonality in the progress we see in these two areas of treatment: empathy, compassion, and understanding. That’s reflected in the words we use, as mentioned above. But it’s also reflected by the fact that the current best-practice model for addiction treatment is the integrated model. That’s an official way of saying that when someone receives treatment, that treatment addresses the whole person, rather than the disorder alone.
Mental Health Disorders and Addiction: PTSD
We published an article recently called “Anxiety Disorders, Substance Use Disorder, and Integrated Treatment” that focused on how anxiety disorders and substance use disorders interact and discussed how the symptoms of both often compound and exacerbate one another, a situation further complicated by the significant overlap between the symptoms of withdrawal from substances of misuse and the symptoms of anxiety disorders.
In that article, we explored data from a long-term study on the co-occurrence of substance use disorders and mental health disorders, and went in-depth on the relationship between substance use disorders, anxiety disorders, and integrated treatment.
One topic we did not discuss in depth, however, was the co-occurrence of post-traumatic stress disorder (PTSD) and SUD. That’s what we’ll do in this article, with an emphasis on a sub-type of PTSD called complex post-traumatic stress disorder (CTPTSD).
PTSD and SUD: The Statistics
We’ll start by summarizing the data from the long-term study we used in our recent article on co-occurring anxiety and SUD. In a nationally representative sample, researchers found that SUD is significantly associated with:
- Posttraumatic stress disorder (PTSD)
- Generalized anxiety disorder (GAD) – mild and severe
In addition, previous research shows:
- 38% of people in treatment for SUD had an anxiety disorder
- 46% of people with SUD meet criteria of PTSD
Now let’s look at data from another nationally representative sample, the 2021 National Survey on Drug Use and Health (2021 NSDUH). In 2021:
- 6.7% of adults in the U.S. had any co-occurring mental illness and substance use disorder
- 2.2% of percent of adults in the U.S. had serious co-occurring mental illness and substance use disorder
We include this data in order to raise awareness about the numbers – 6.7 percent of adults in the U.S. is 17.2 million people, and 2.2 percent of adults in the U.S. is 5.7 million people – and also as a starting point for identifying the differences between CTPSD and PTSD, and how those differences affect the development and treatment of substance use disorder.
Co-Occurring Disorders, Trauma, and Recovery
The difference between any co-occurring mental illness and serious co-occurring mental illness is defined by the level of disruption the mental illness causes. A mental illness disrupts daily life but does not prevent an individual from carrying out the basic functions of daily life. A serious mental illness can disrupt daily life to the extent that an individual is unable to carry out the basic functions of daily life.
With regards to recovery, a mental illness creates challenges and may slow the process as the individual in treatment and their therapist and counselors work through issues related to both the mental illness and the substance use disorder. A serious mental illness makes recovery more challenging, because the interaction between the mental illness and the substance use disorder can be extremely complex, which may slow the recovery process further as the individual and their treatment team take the time to understand and work through the issues they uncover.
PTSD and Recovery
The same distinctions apply to the PTSD and CPTSD. We’ll go into detail in a moment, but the primary difference between PTSD and CPTSD is the level of disruption the disorders cause. PTSD is disruptive and can slow treatment progress. CPTSD, on the other hand, can be extremely disruptive – to the point of debilitating. It’s a serious mental illness. It can complicate and slow the treatment process more than typical PTSD.
This is one of reasons there’s an approach to treatment called trauma-informed care, which we discuss in our article “What is Trauma-Informed Care?” It’s important for clinicians working in addiction treatment to understand PTSD and how it interacts with SUD and SUD treatment. It’s also important for clinicians to understand this new subtype of PTSD called CPTSD, and realize that its symptoms and associated behaviors can create obstacles to treatment progress for individuals with co-occurring SUD and CPTSD.
It’s not only important for clinicians, but also important for individuals in treatment who may have PTSD. Understanding CPTSD can help them – and help their families – manage the complications that it may create during recovery.
What is CPTSD?
Complex PTSD, as a sub-type of PTSD, was first identified in the early 1990s. The Diagnostic and Statistical Manual of Behavioral Disorders, Volume 5 (DSM-V), published in 2013, does not distinguish between PTSD and CPTSD, whereas the International Classification of Diseases, Volume 11 (ICD-11), published in 2019, created a separate set of diagnostic criteria for a new disorder, CTPSD. We’ll use information from a 2020 publication called “Complex Post-Traumatic Stress Disorder: A New Diagnosis In ICD-11” to define CPTSD, present its symptoms, and talk about how it affects the process of recovery from SUD.
Here’s how the ICD-11 defines CPTSD:
“Complex post-traumatic stress disorder (complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible.”
That’s where we see the primary difference between PTSD and CTPSD. A single traumatic event can cause PTSD. In contrast, CPTSD requires a series of traumatic events over time, with the added criterion “from which escape is difficult or impossible.”
That creates a category that can include the experiences of domestic abuse and childhood abuse survivors, which clinicians working in addiction treatment often discover while working with adults with co-occurring SUD and PTSD.
Now let’s look at the diagnostic criteria for CPTSD, as defined by the ICD-11.
Chronic PTSD: Diagnosis
- All criteria for PTSD must be met.
- If all PTSD criteria are met, an individual must show:
- Disrupted affect regulation. [Note: Affect relation is how we respond to our emotions, especially when they’re intense an overwhelming: positive affect relation means our emotions do impair our daily function, while negative affect regulation means our emotions do impair our daily function.]
- Feelings of worthless/defeat
- Those beliefs are accompanied by feelings of shame, guilt, failure related to the traumatic event
- Problems creating lasting relationships
- Difficulty developing intimate relationships
- The above symptoms create significant disruption in personal, family, social, educational, and occupational domains of life
Once an individual meets those diagnostic criteria, the type of trauma they experience must meet an expanded set of criteria.
Chronic PTSD: Specific Diagnostic Components
- Exposure to any of the following over a prolonged period of time, from which the individual could not escape:
- Childhood sexual abuse
- Childhood physical abuse
- Domestic violence
- Proximity to/experience of organized violence
- The core symptoms of PTSD assert themselves after the prolonged trauma:
- Intense avoidance of any reminder of trauma
- Ongoing sense of threat
Finally, to meet the full criteria for CPTSD, the traumatic events and stressors are most often interpersonal.
Chronic PTSD: Types of Trauma
- Caused by maltreatment or mistreatment by other humans
- The traumas are distinct from those caused by natural disasters, such as earthquakes, hurricanes, or tornados
- The traumas are distinct from those caused by accidents, such as train wrecks, motor vehicle accidents, or other accidents that result in severe injury to the self or others.
That’s a lot of information to digest. Those last three bullet points help us understand how the presence of CPTSD can impact recovery. We’ll talk about that now.
CPSTD, Connection, and Recovery
Those last three bullet points indicate that the type of trauma that causes CPTSD is specific. It’s maltreatment and/or mistreatment by other people. That type of trauma – not trauma caused by accidents or disasters – leads to severe disruptions in affect regulation, leads people with CPTSD to believe they’re worthless or damaged, prevents them from forming lasting, intimate relationships, and impairs their ability to thrive in family, school, social, and work situations.
The reason CPTSD can interrupt or slow the recovery process is that those are the things that a person in recovery needs the most. People in recovery need positive affect regulation – i.e. the ability to manage their reactions to their emotions – or the intensity of their emotions can inhibit treatment progress and increase risk of relapse due to self-medication. They need self-esteem. They need the belief they can recover and create a life without substance use. But the symptoms of CPTSD threaten their ability to rediscover their self-esteem and hope for the future. People in recovery need the positive support of peers, family, and loved ones. But the symptoms of CPTSD inhibit their ability to form those valuable, sustaining connections.
A core principle of integrated treatment is addressing mental health disorders and substance use disorders in a comprehensive, holistic manner. We now understand treating one and not treating the other often impairs progress for both. In other words, for a person to heal, grow and thrive in addiction recovery, their treatment needs to address everything in their lives that can affect their addiction and their recovery.
Treatment for CPTSD
In order to treat CPTSD, the International Society for Traumatic Stress Studies recommends a three-phase approach, which we’ll share now.
Treating Complex PTSD in Adults
This phase prioritizes creating feelings of safety, reducing symptoms, and improving emotional, social, and psychological skills
This phase prioritizes resolving traumatic experiences in order to build an adaptive concept of and approach to the self, relationships, and the world. In this phase, experts consider standard or adapted trauma-informed cognitive–behavioral therapy the most effective approach.
This phase prioritizes consolidation of treatment gains. An individual reviews new emotional, social, and psychological skills. Then they prepare for more active and engaged participation in family, social, educational, and occupational domains of function.
That’s the blueprint for treating this subtype of PTSD, which is more common than most people think. In fact, a recent study examined a nationally representative sample of U.S. adults and identified a prevalence rate of 3.5 percent, which is just over 9 million people. Therapists working in addiction recovery can use this blueprint to enhance and inform any treatment plan for an individual with clinically diagnosed co-occurring SUD and PTSD. They can also use the information presented throughout this article – along with the source material and references – to help educate peers working in treatment recovery. And most importantly, they can use this new knowledge to educate their patients and patients’ families about the importance of addressing co-occurring mental health disorders and substance use disorders in a comprehensive, trauma-informed manner, following the principles of integrated treatment.