Post-traumatic stress disorder and substance use disorders

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Post-traumatic stress disorder (PTSD) can affect about 3.6% of the U.S. population each year, and 6.8% of the U.S. population over a lifetime. [1] 8.4% of people in the U.S. are diagnosed with substance use disorders (SUD). [2] Of those with a diagnosis of PTSD, a co-occurring, or comorbid diagnosis of a SUD is present in 20–35% of that clinical population.

Contents

Prevalence of SUD and PTSD may increase depending on specific populations. For example, the prevalence of both PTSD and SUD is higher in combat veterans. [3] Other populations that are disproportionately affected by both of these disorders include women, [4] members of the black and hispanic populations, [5] and members of the LGBTQ community. [6] Alcohol use disorder (AUD) is the leading cause of SUD amongst veterans who have experienced trauma. [7] While research indicates that alcohol is the most abused substance by those diagnosed with PTSD, additional substances with high abuse rates include other depressants such as cannabis and opiates, as well as the stimulant cocaine." [8]

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Worsening PTSD symptoms are associated with increased SUD and poor treatment response [9] Of those with a SUD diagnosis, current PTSD is present in 25–50%, and lifetime PTSD is present in 15–40%, averaging 30% overall. [3] Though roughly a third of all people diagnosed with SUD also have PTSD, there is not yet consistent protocol for SUD treatment centers to screen for both PTSD and SUD symptomology upon intake. [10]

The presence of both PTSD and SUD can hinder outcomes of those seeking treatment for either PTSD or SUD. A few different treatment options include trauma focused treatments such as psychotherapy, non trauma focused treatments, and pharmacological treatments like medications that can help reduce withdrawal symptoms or SSRI's.Those who experience both diagnoses may generally have poorer overall functioning and worse overall well-being than each diagnosis by itself. [3] [11] This can manifest as being hospitalized more frequently, experiencing increased levels of legal issues, have less social support, and have a harder time retaining employment. [12] [11] In treatment these individuals can have high dropout rates, respond poorly to the treatment of PTSD in general, have greater levels of addiction severity, and shorter periods of remission for substance use treatment. [11] [10] [13]

Etiological theory

Each of the subsequent theories about the causal link between PTSD and SUD have varying levels of empirical support. These etiological theories are not mutually exclusive, and features of more than one can be present for an individual with dual diagnoses of SUD and PTSD. [14] No one clear etiological link has been established between SUD and PTSD.

Susceptibility hypothesis

The susceptibility hypothesis suggests that the substance use may increase the risk of PTSD developing after a traumatic event. [12] Individuals who use substances may lack appropriate coping mechanisms to deal with daily stressors before the traumatic event, they may be less equipped than individuals who do not use substances to cope with extreme stress. Thus, these individuals may be more susceptible to developing PTSD following a traumatic event. [12]

Implication of coping strategies

Coping style has recurrently been discussed as a third-party influence on the presence of dual diagnosis for PTSD and SUD. [12] Avoidant coping styles have been shown to have a strong relationship to both PTSD and SUD individually, as well as presentation of concomitant PTSD and SUD together. [3] Those with avoidant coping styles attempt to avoid interacting with or experiencing thoughts, feelings, or physical sensations reminiscent of the stressor in order to gain relief from the distress it causes. [3] Substance use, for example, can allow a person to attempt to escape the distressing thoughts, feelings or physical sensations associated with the stressor the person is attempting to avoid experiencing. An avoidant coping style can therefore increase an individual's likelihood to seek means to avoid experiencing distressing sensations and increase likelihood of substance use overall. [3]

PTSD affects substance use disorders

Individuals with comorbid PTSD and SUD tend to engage in more frequent and heavier substance use than individuals who have SUD alone. [10] Additionally, research suggests that symptoms of PTSD can hinder abstaining from substance use. [10] More generally, individuals with a dual diagnosis of PTSD and SUD have shown to be at increased risk meeting criteria for other psychiatric diagnosis in additional to PTSD and SUD when compared to those with SUD alone. Those with a dual diagnosis of PTSD and SUD have also been shown to seek treatment at higher rates than those who experience SUD alone. [14]

How substance use disorders affect PTSD

The self medication hypothesis, as well as behavioral and emotional conditioning plays a role for people with dual diagnoses of PTSD and SUD. [14] Symptoms of withdrawal, increased heart rate, sweating can mirror a human's natural physiological responses to fear, and can therefore trigger fear responses associated with that person's traumatic experience. [14] Those with comorbid PTSD and SUD diagnoses may seek to avoid experiencing withdrawal to avoid experiencing these sensations that can act as fear inducing and triggering experiential catalysts. [14] Additionally, individuals who chronically use substances as a form of self-medication for PTSD symptoms strengthen an automatic mental link between PTSD symptoms and the substance use itself via conditioning. [13] Stress is also a component of PTSD that may lead to drug use, due to the norepinephrine that is released from the stress response of the body. [15] Therefore, conditioned link between PTSD and substance use may trigger craving for substances when it arises, potentially increasing psychological dependence and complicating treatment outcomes for both diagnoses. [14]

Implicated brain systems

Hippocampus and amygdala

The hippocampus, which is responsible for encoding memory within the brain, is implicated in both PTSD and SUD. PTSD and SUD have been found to interfere with typical hippocampal functioning. [11] Studies of the involvement of the hippocampus in both sole PTSD and SUD diagnosis as well as comorbid PTSD and SUD evidence that the manifestation of these diagnosis are related to decreased hippocampal volume. [11]

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Hypothalamic pituitary adrenal axis and corticotropin-releasing hormone. The hypothalamic pituitary adrenal (HPA) axis is responsible for the activation of the hormonal stress response system within the human body. [11] Corticotropin-releasing hormone (CRH) is activated by the HPA axis during times of stress. [11] Heightened CRH levels have been shown during symptoms of PTSD (particularly for hyperarousal), drug seeking behavior, substance withdrawal, and drug relapse in humans. Research has conveyed that increased levels of CRH are also related to experiences of euphoria. [11] As CRH levels are elevated in PTSD, this can personify feelings of euphoria experienced when an individual uses substances and increase addiction severity as a result of positive reinforcement from euphoric sensation. [11] This can also affect the interplay between withdrawal symptoms and the increased experience of hyperarousal. As increased levels of CRH have been linked to both withdrawal and hyperarousal, those affected by both diagnoses of PTSD and SUD may subsequently continue to seek substances as a means to avoid these escalated aversive sensations. [11] The described relationship has been used to evidence the self-medication hypothesis. [11]

Treatment options

Assessment of effectiveness of treatment for comorbid PTSD and SUD has fluctuated. While some treatments for cooccurring PTSD and SUD have shown promising in symptom reduction for both diagnoses, many have not evidenced the ability to be more effective than treatment of PTSD or SUD alone. [3] [14] [16] This is further complicated by high rates of treatment dropout and substance relapse in studies of treatment in this population. [3] [17] Research has focused on two major forms of treatment for those with comorbid SUD and PTSD: treatments that focus on the traumatic experience(s), and treatments that do focus on traumatic experience(s). [3] Research has not definitely concluded that any form of treatment adequately addresses the treatment needs of those who have both PTSD and SUD.

Non-trauma focused treatments

Treatments that are non-trauma focused do not emphasize the individual's exposure to the trauma memory as a means to treat both PTSD and SUD. [3] Seeking safety is the most well-known non-trauma focused treatment for SUD and PTSD and is based on cognitive behavior therapy. [3] The goal of seeking safety's is to increase the safety of the individual's coping style by addressing thoughts, behaviors, and interpersonal interactions for the individual seeking treatment. [3] Additional non-trauma focused treatments include but are not limited to CBT for PTSD (CBT-P) in existing addiction treatment programs, substance dependency posttraumatic stress disorder (SDPT), and transcend therapy. [14] Other non-trauma focused treatments also include holistic alternatives such as yoga, meditation and acupuncture, which have shown to be effective in treating PTSD and SUD specifically in victims of sexual assault and veterans. [18]

Trauma focused treatments

Trauma focused forms of treatment aim to focus on, process, and identify the meaning of the traumatic experience of the individual while concurrently addressing needs of comorbid SUD. [14] A modified version of seeking safety, seeking safety plus exposure therapy revised, incorporates imagined exposure to the traumatic event into the seeking safety treatment protocol. [14] Concurrent treatment of PTSD and cocaine dependence (CTPCD), also referred to as concurrent treatment of PTSD and substance use disorders with prolonged exposure (COPE), merges typical prolonged exposure protocol for the treatment of PTSD with CBT protocol for SUD. [14] Symptom outcomes have shown improvement in the assessment of the efficacy of trauma-focused treatments for both PTSD and SUD, however effects of the treatment have been small, and they have not evidenced ability to treat both disorders over and above the treatment of either PTSD or SUD alone. [3] [14] [19] Of note, research has conveyed that exposure-based treatments for individuals with PTSD and SUD see high dropout rates, with rates typically peaking around the session that introduces exposure of trauma-based memories to the client. [17] This has created impediments for assessing the efficacy of trauma-focused therapies for people with both SUD and PTSD compared to assessing the efficacy of treating PTSD and SUD separately. [10] [17]

Pharmacological and integrated psychotherapy treatments for PTSD and AUD

Research study at John Hopkins using psilocybin for depression symptoms Johns Hopkins psilocybin session room-SessionRm 2176x.jpg
Research study at John Hopkins using psilocybin for depression symptoms

Pharmacological interventions alone or in combination with psychotherapy have been examined in the treatment of the PTSD and AUD comorbidity, with varying success. The opioid antagonist naltrexone is generally effective when administered alone in reducing drinking outcomes, with no effect on PTSD symptoms, while the selective serotonin reuptake inhibitor (SSRI) sertraline is generally ineffective in reducing PTSD symptoms or AUD symptoms when administered without psychotherapy. [20] Research integrating naltrexone with an exposure-based treatment for PTSD, such as prolonged exposure, has demonstrated modest support for this integrative framework on the reduction of drinking outcomes and amelioration of PTSD symptoms. [21] New research is currently evaluating the effects of classic psychedelics, including MDMA, psilocybin, LSD, and ayahuasca, on both PTSD and SUD. Current results have found that psychedelic therapy has had successful results in the treatment of both disorders, especially with MDMA and psilocybin. [22]

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Dissociation is a concept that has been developed over time and which concerns a wide array of experiences, ranging from a mild emotional detachment from the immediate surroundings, to a more severe disconnection from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a false perception of reality as in psychosis.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences, with extreme examples being violence, rape, or a terrorist attack. The event must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se.

Acute stress reaction is a psychological response to a terrifying, traumatic or surprising experience. It may bring about delayed stress reactions if not correctly addressed. Acute stress may present in reactions which include but are not limited to: intrusive or dissociative symptoms, and reactivity symptoms such as avoidance or arousal. Reactions may be exhibited for days or weeks after the traumatic event.

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Gender is correlated with the prevalence of certain mental disorders, including depression, anxiety and somatic complaints. For example, women are more likely to be diagnosed with major depression, while men are more likely to be diagnosed with substance abuse and antisocial personality disorder. There are no marked gender differences in the diagnosis rates of disorders like schizophrenia and bipolar disorder. Men are at risk to suffer from post-traumatic stress disorder (PTSD) due to past violent experiences such as accidents, wars and witnessing death, and women are diagnosed with PTSD at higher rates due to experiences with sexual assault, rape and child sexual abuse. Nonbinary or genderqueer identification describes people who do not identify as either male or female. People who identify as nonbinary or gender queer show increased risk for depression, anxiety and post-traumatic stress disorder. People who identify as transgender demonstrate increased risk for depression, anxiety, and post-traumatic stress disorder.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

<span class="mw-page-title-main">Military sexual trauma</span> U.S. legal term for sexual assault or harassment during military service

As defined by the United States Department of Veterans Affairs, military sexual trauma (MST) are experiences of sexual assault, or repeated threatening sexual harassment that occurred while a person was in the United States Armed Forces.

Memory and trauma is the deleterious effects that physical or psychological trauma has on memory.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

<span class="mw-page-title-main">Post-traumatic stress disorder among athletes</span> Prevalence of PTSD among athletes

Posttraumatic stress disorder (PTSD) is a cognitive disorder, which may occur after a traumatic event. It is a psychiatric disorder, which may occur across athletes at all levels of sport participation.

Operational stress injury or OSI is a non-clinical, non-medical term referring to a persistent psychological difficulty caused by traumatic experiences or prolonged high stress or fatigue during service as a military member or first responder. The term does not replace any individual diagnoses or disorders, but rather describes a category of mental health concerns linked to the particular challenges that these military members or first responders encounter in their service. There is not yet a single fixed definition. The term was first conceptualized within the Canadian Armed Forces to help foster understanding of the broader mental health challenges faced by military members who have been impacted by traumatic experiences and who face difficulty as a result. OSI encompasses a number of the diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system, with the common thread being a linkage to the operational experiences of the afflicted. The term has gained traction outside of the military community as an appropriate way to describe similar challenges suffered by those whose work regularly exposes them to trauma, particularly front line emergency first responders such as but not limited to police, firefighters, paramedics, correctional officers, and emergency dispatchers. The term, at present mostly used within Canada, is increasingly significant in the development of legislation, policy, treatments and benefits in the military and first responder communities.

The term functional somatic syndrome (FSS) refers to a group of chronic diagnoses with no identifiable organic cause. This term was coined by Hemanth Samkumar. It encompasses disorders such as chronic fatigue syndrome, fibromyalgia, chronic widespread pain, temporomandibular disorder, irritable bowel syndrome, lower back pain, tension headache, atypical face pain, non-cardiac chest pain, insomnia, palpitation, dyspepsia and dizziness. General overlap exists between this term, somatization and somatoform.

<span class="mw-page-title-main">Trauma and first responders</span> Trauma experienced by first responders

Trauma in first responders refers to the psychological trauma experienced by first responders, such as police officers, firefighters, and paramedics, often as a result of events experienced in their line of work. The nature of a first responder's occupation continuously puts them in harm's way and regularly exposes them to traumatic situations, such as people who have been harmed, injured, or killed.

Cannabis use and trauma is the contribution that trauma plays in promoting the use and potential abuse of cannabis. Conversely, cannabis use has been associated with the intensity of trauma and PTSD symptoms. While evidence of efficacious use of cannabis is growing in novelty, it is not currently recommended.

Being exposed to traumatic events such as war, violence, disasters, loss, injury or illness can cause trauma. Additionally, the most common diagnostic instruments such as the ICD-11 and the DSM-5 expand on this definition of trauma to include perceived threat to death, injury, or sexual violence to self or a loved one. Even after the situation has passed, the experience can bring up a sense of vulnerability, hopelessness, anger and fear.

Social constraints are a psychological term that can be defined as "any social condition that causes a trauma survivor to feel unsupported, misunderstood, or otherwise alienated from their social network when they are seeking social support or attempting to express trauma-related thoughts, feelings, or concerns." Social constraints are most commonly defined as negative social interactions which make it difficult for an individual to speak about their traumatic experiences. The term is associated with the social-cognitive processing model, which is a psychological model describing ways in which individuals cope and come to terms with trauma they have experienced. Social constraints have been studied in populations of bereaved mothers, individuals diagnosed with cancer, and suicide-bereaved individuals. There is evidence of social constraints having negative effects on mental health. They have been linked to increased depressive symptoms as well as post-traumatic stress disorder symptoms in individuals who have experienced traumatic events. There seems to be a positive association between social constraints and negative cognitions related to traumatic events. Social constraints have also been linked to difficulties in coping with illness in people who have been diagnosed with terminal illness such as cancer.

Psychological trauma in adultswho are older, is the overall prevalence and occurrence of trauma symptoms within the older adult population.. This should not be confused with geriatric trauma. Although there is a 90% likelihood of an older adult experiencing a traumatic event, there is a lack of research on trauma in older adult populations. This makes research trends on the complex interaction between traumatic symptom presentation and considerations specifically related to the older adult population difficult to pinpoint. This article reviews the existing literature and briefly introduces various ways, apart from the occurrence of elder abuse, that psychological trauma impacts the older adult population.

References

  1. ↑ Blanco, Carlos (2011-07-15), "Epidemiology of PTSD", Post-Traumatic Stress Disorder, John Wiley & Sons, Ltd, pp. 49–74, doi:10.1002/9781119998471.ch2, ISBN   9781119998471
  2. ↑ "SAMHSA Issues Group Therapy Guide for Substance Use Disorders Treatment". 2005. doi:10.1037/e442842005-001.{{cite journal}}: Cite journal requires |journal= (help)
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 Roberts, Neil P.; Roberts, Pamela A.; Jones, Neil; Bisson, Jonathan I. (2015). "Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis". Clinical Psychology Review. 38: 25–38. doi:10.1016/j.cpr.2015.02.007. ISSN   0272-7358. PMID   25792193.
  4. ↑ Greenfield, Shelly F.; Back, Sudie E.; Lawson, Katie; Brady, Kathleen T. (2010-06-01). "Substance Abuse in Women". Psychiatric Clinics of North America. Women's Mental Health. 33 (2): 339–355. doi:10.1016/j.psc.2010.01.004. ISSN   0193-953X. PMC   3124962 . PMID   20385341.
  5. ↑ Alegría, Margarita; Fortuna, Lisa R.; Lin, Julia Y.; Norris, Fran H.; Gao, Shan; Takeuchi, David T.; Jackson, James S.; Shrout, Patrick E.; Valentine, Anne (December 2013). "Prevalence, Risk, and Correlates of Posttraumatic Stress Disorder Across Ethnic and Racial Minority Groups in the United States". Medical Care. 51 (12): 1114–1123. doi:10.1097/MLR.0000000000000007. ISSN   0025-7079. PMC   3922129 . PMID   24226308.
  6. ↑ Marchi, Mattia; Travascio, Antonio; Uberti, Daniele; Micheli, Edoardo De; Grenzi, Pietro; Arcolin, Elisa; Pingani, Luca; Ferrari, Silvia; Galeazzi, Gian M. (January 2023). "Post-traumatic stress disorder among LGBTQ people: a systematic review and meta-analysis". Epidemiology and Psychiatric Sciences. 32: e44. doi:10.1017/S2045796023000586. ISSN   2045-7960. PMC   10387489 . PMID   37431310.
  7. ↑ Heinz, Adrienne J.; Pennington, David L.; Cohen, Nicole; Schmeling, Brandi; Lasher, Brooke A.; Schrodek, Emily; Batki, Steven L. (July 2016). "Relations Between Cognitive Functioning and Alcohol Use, Craving, and Post-Traumatic Stress: An Examination Among Trauma-Exposed Military Veterans With Alcohol Use Disorder". Military Medicine. 181 (7): 663–671. doi:10.7205/MILMED-D-15-00228. ISSN   0026-4075. PMC   4940120 . PMID   27391620.
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  15. ↑ Sofuoglu, Mehmet; Rosenheck, Robert; Petrakis, Ismene (2014-02-01). "Pharmacological treatment of comorbid PTSD and substance use disorder: Recent progress". Addictive Behaviors. 39 (2): 428–433. doi:10.1016/j.addbeh.2013.08.014. ISSN   0306-4603. PMC   3855907 . PMID   24035645.
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  19. ↑ Torchalla, Iris; Nosen, Liz; Rostam, Hajera; Allen, Patrice (2012). "Integrated treatment programs for individuals with concurrent substance use disorders and trauma experiences: A systematic review and meta-analysis". Journal of Substance Abuse Treatment. 42 (1): 65–77. doi:10.1016/j.jsat.2011.09.001. ISSN   0740-5472. PMID   22035700.
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  22. ↑ Reiff, Collin M.; Richman, Elon E.; Nemeroff, Charles B.; Carpenter, Linda L.; Widge, Alik S.; Rodriguez, Carolyn I.; Kalin, Ned H.; McDonald, William M. (May 2020). "Psychedelics and Psychedelic-Assisted Psychotherapy". American Journal of Psychiatry. 177 (5): 391–410. doi:10.1176/appi.ajp.2019.19010035. ISSN   0002-953X. PMID   32098487.
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