Comorbid PTSD and Substance Use Disorder

By Lori Ryland, Ph.D., LP, CAADC, BCBA-D, Chief Clinical Officer, Pinnacle Treatment Centers

A significant percentage of individuals with a mental health disorder also grapple with substance abuse or addiction. This often raises the question: “Which came first, the substance abuse or the mental illness?” In many cases, alcohol and drugs are used to self-medicate the troubling symptoms of mental health disorders. This is particularly common in individuals who suffer from posttraumatic stress disorder (PTSD) and have a co-occurring, or comorbid substance use disorder (SUD).

Research suggests that when PTSD and SUD co-occur, as opposed to only one of the two disorders being present, an individual’s day-to-day functioning is even more impaired, and treatment is less likely to succeed.

What is Posttraumatic Stress Disorder (PTSD)?

PTSD is a serious and often debilitating psychiatric disorder that’s triggered by a severe traumatic event. In the DSM-5 (the most recent version of the diagnostic manual used by mental health professionals), the disorder is categorized under “Trauma- and Stressor-Related Disorders.” Posttraumatic stress disorder can develop at any point in a person’s life. The symptoms often persist for a lifetime, especially if there is no treatment. Some of the most common types of trauma that may lead to the development of PTSD include:

  • Combat exposure or living in a war zone
  • Rape or other violent sexual assault
  • Violent non-sexual assault
  • Experiencing a serious accident or injury
  • Childhood abuse
  • Natural disasters (e.g. earthquakes, hurricanes)
  • Witnessing the severe injury or death of another person

Not everyone who experiences a severe trauma goes on to develop PTSD, but a significant percentage – some estimate around 20% – do go on to develop the disorder.

Symptoms of PTSD

Individuals are diagnosed with PTSD when symptoms of the disorder have been present for at least 30 days. Symptoms of PTSD fall primarily into three categories:

  • Reliving the traumatic event in some manner, including:
    • Flashbacks, nightmares, or intrusive images
    • Intense physical or emotional responses such as panic, chills, or profuse sweating
    • Pounding or racing heart when something triggers memories of the event
  • Hyperarousal or constantly being on guard, including:
    • Being easily startled or jumpy
    • Feeling irritable, anxious, or nervous
    • Outbursts of anger
    • Difficulty concentrating
    • Trouble sleeping
  • Avoiding reminders of the traumatic event, including:
    • Self-medicating with alcohol or drugs
    • Going to significant lengths to avoid people, places, anniversaries, or mementos associated with the traumatic event
    • Avoiding talking about the trauma
    • Isolating from others
    • Losing interest in daily activities or trying new things
    • Emotional numbness

Other PTSD symptoms may include:

  • Denial that the trauma ever took place
  • Bouts of intense sadness
  • Shame and guilt about the traumatic event
  • Hopelessness
  • Suicidal thoughts and/or behaviors
  • Rehashing details of the traumatic event over and over
  • Difficulty expressing thoughts or feelings
  • Feeling suspicious or paranoid
  • Trust issues
  • An expectation of an early death/not talking about the future or making future plans
  • Night terrors
  • Somatic complaints
  • Fatigue
  • Chronic pain

Disorders that may Co-Occur with PTSD

In addition to comorbid substance use disorder, it’s not uncommon for other psychiatric disorders to also co-occur with PTSD (sometimes in addition to SUD) including:

  • Depression
  • Borderline personality disorder
  • Panic Disorder
  • Social Phobia
  • Eating disorders

When these disorders co-occur with PTSD it complicates the clinical picture. If SUD is also part of the comorbid diagnosis it makes treatment especially challenging. Therefore, it’s extremely important to work with professionals who are experienced in treating PTSD and understand the nuances of comorbidity.

PTSD Statistics 

Following are several statistics regarding the prevalence of PTSD as well as comorbid PTSD and SUD:

  • The National Comorbidity Survey results published in 1995, involving more than 5,800 individuals between the ages of 15 and 54, showed that 7.8% are likely to have PTSD at some point in their lifetime. This same study also showed a 26.6% lifetime prevalence of substance use disorders.
  • The 1995 National Comorbidity Survey also showed that 28% of females with PTSD and 52% of males with PTSD meet the lifetime criteria for alcohol dependence or abuse, and 27% of females and 35% of men meet the criteria for drug dependence or abuse.
  • According to the Sidran Traumatic Stress Institute, Inc., more than 13 million Americans have PTSD at any given time, and around 8% of adults will develop the disorder at some point in their lifetime.
  • Studies show that PTSD is present in more than 25% to as many as nearly 50% of patients with SUD.
  • Many veterans with PTSD have a co-occurring substance use disorder (SUD). According to the Veterans Administration website, recent statistics indicate:
  • SUD co-occurs in more than 20% of veterans with PTSD
  • Approximately 10% of veterans from the Afghanistan and Iraq wars, who’ve been treated at the VA, struggle with substance abuse or addiction
  • Nearly 33% of veterans who’ve sought help for SUD have comorbid PTSD

Challenges of Comorbid PTSD and SUD

When individuals with PTSD also have a substance use disorder, the challenges they face often become significantly worse than if they had only one of the two disorders. They’re more likely to:

  • Experience greater impairment in social and overall functioning
  • Engage in violent behavior
  • Drop out of treatment or not comply with their treatment regimen
  • Not make progress while in treatment
  • Engage in suicidal behavior and attempts*
  • Have more legal issues
  • Have more chronic health issues

*The disinhibiting effects of alcohol increase the risk of an actual suicide attempt in individuals with mental illness who’ve been struggling with suicidal thoughts. There is also a potentially higher risk of fatal drug overdoses, whether accidental or intentional, in individuals with comorbid PTSD and a drug-related substance use disorder.

The Connection between PTSD, Substance Abuse, and Addiction

Posttraumatic stress disorder can make day to day life very difficult. The desire to numb the emotional pain, stop the intrusive images, forget about the trauma – at least temporarily, or just get a decent night’s sleep often leads to alcohol or drug abuse and, for many, eventual addiction or dependence. The extreme stress associated with PTSD also alters brain chemistry, which plays a role in the substance-seeking behaviors so often seen in this disorder.

Treatment for Comorbid PTSD and Substance Use Disorder

It’s imperative to use a dual diagnosis treatment approach for individuals who suffer from both PTSD and SUD. Dual diagnosis treatment is designed specifically to treat both disorders simultaneously rather than separately. If someone with comorbid PTSD and SUD engages in a treatment program that focuses only on the substance use disorder, it’s highly unlikely they will attain lasting sobriety. If the PTSD is treated without addressing the accompanying substance use disorder, treatment will have very limited benefit.

An integrated dual diagnosis approach will usually involve a combination of treatment modalities, including individual therapy, group therapy, family therapy, psychoeducation, and pharmacotherapy.  

Therapeutic approaches may include:

Prolonged Exposure Therapy (PE)

PE helps reduce the anxiety and distress associated with PTSD. Through repeated in vivo and imagined exposure, individuals face the painful feelings, thoughts, memories, and situations they have been avoiding. This repeated exposure decreases their power to cause distress while building confidence and instilling a sense of mastery.

Cognitive Behavioral Therapy (CBT) and Cognitive Processing Therapy (CPT)

CBT focuses on identifying and changing irrational thought patterns and underlying beliefs. A specific type of CBT, known as cognitive processing therapy (CPT), teaches individuals how to evaluate and change distressing thoughts, about themselves and the world, that have developed as a result of trauma. CPT has been demonstrated to be an effective trauma treatment and enables the patient in creating a new understanding and conceptualization of the traumatic event so that it reduces the negative impact on current life.

Eye Movement Desensitization Reprocessing (EMDR)

EMDR is a structured, short-term, non-traditional type of therapy that utilizes specific eye movement rhythms. It was developed to help individuals process a traumatic event in a way that diminishes its power over them. It’s been found to be very effective in the treatment of PTSD.

Dialectical Behavior Therapy (DBT)

DBT is a type of cognitive behavioral therapy. It helps individuals learn how to manage intense emotions, cope with distress in healthy ways, develop better interpersonal skills, and practice mindfulness.

Seeking Safety Therapy

Seeking Safety Therapy focuses on the present rather than requiring individuals to talk about the past traumatic event(s). The primary goal is to help individuals find a sense of safety in their thoughts, actions, feelings, and relationships. It also helps individuals rediscover their goals and values.

Group Therapy

Group therapy is frequently used in addiction treatment. It gives individuals with comorbid PTSD and SUD an opportunity to share their experiences, emotions, and thoughts with others who can relate. Group therapy is especially effective in reducing the sense of isolation experienced by many individuals with PTSD.

Family Therapy

Both PTSD and addiction affect the entire family. Family therapy allows the individual in treatment as well as his or her family members process emotions while working on establishing effective ways of communicating with each other and providing appropriate support. Family therapy can also help family members have a better understanding of both PTSD and addiction.

Pharmacotherapy

Medication may be prescribed to help alleviate the anxiety, depression, paranoia, and sleep problems that often accompany PTSD. It may also be used to manage withdrawal symptoms and reduce cravings.

Treatment Goals for Comorbid PTSD and SUD

The primary focus of any dual diagnosis treatment program is to help individuals achieve and maintain sobriety while also learning to effectively manage both their substance use disorder and other mental health disorder(s).

This can be accomplished when new, healthy coping skills have been established and necessary changes are made in the individual’s environment (e.g. things that trigger the urge to use or present frequent temptations) to reduce the risk of relapse. Treatment also strives to diminish or eliminate cravings for alcohol and/or drugs and provide tools to manage them should they occur.

Posttraumatic stress disorder can result in a lifetime of emotional pain and anguish if left untreated. Its potentially debilitating effects are exacerbated substantially when a substance use disorder is also present. Fortunately, treatment is available, and it can be highly effective. Our trained, experienced, and caring professionals at Pinnacle Treatment Centers can help you attain a happier, healthier life and brighter future.