Post-Traumatic Stress Disorder Awareness Month Part II: PTSD and Substance Use Disorders

In our first post about PTSD Awareness Month – June is PTSD Awareness Month – we offered a basic definition of PTSD, listed the potential causes and common symptoms, then provided statistics about the prevalence of PTSD in adults and adolescents in the U.S.

Here’s a quick recap of all that information.

PTSD defined:
Traumatic events that may lead to PTSD:
  • War
  • Rape or sexual assault
  • Non-sexual assault
  • Serious accident or injury
  • Childhood physical, emotional, or sexual abuse
  • Natural disasters such as floods, hurricanes, wildfires, tornadoes
  • Severe injury or death of another person
Common symptoms of PTSD may include some or all of the following:
  • Reliving the Event. Symptoms may include:
    • Nightmares, flashbacks, disturbing memories/images related to the event
    • Physical responses like panic attacks, chills, or sweating.
    • Racing, pounding heart when reminded of the event.
  • Avoiding Reminders of the Event. Symptoms may include:
    • Avoiding people, places, or objects related to the event.
    • Avoiding anniversaries of the event
    • Refusing to discuss the event with others
  • Negative Changes After the Event. Symptoms may include:
    • Isolation from family, friends, and peers
    • Constant negative thoughts or feelings about oneself
    • Constant negative thoughts or feelings about the world
      • Feeling suspicious or paranoid
    • Inability to remember the event
    • Emotional distance/aloofness/numbness
    • Self-medication with alcohol or drugs
    • Fatigue
    • Chronic Pain
  • Hyperarousal.  Symptoms may include:
    • Being jumpy, on edge, and easily startled
    • Constantly feeling anxious, nervous, and irritable
    • Outbursts of anger unrelated or disproportionate to the apparent trigger of the anger
    • Insomnia
    • Problems concentrating
Prevalence of PTSD in adolescents:
  • 15-43% of children and teens experience a traumatic event at some point during childhood.
  • Of those, 5% develop PTSD – that’s about 2 million.
    • 5% develop PTSD with severe impairment – about 630,000.
  • 8% of females develop PTSD – about 3.3 million
  • 3% of males develop PTSD – just under 1 million

PTSD and Substance Use Disorders: The Connection

There’s no question in the minds of mental health professionals that there’s a connection between post-traumatic stress disorder and substance use disorder. The evidence – represented by the statistics presented above – is impossible to ignore, especially in the adolescent population.

This situation makes treatment and diagnosis tricky.

When an individual has two or more mental health disorders, the disorders are called co-occurring or co-morbid, and the individual receives what’s called a dual diagnosis. A dual diagnosis complicates treatment, especially when symptoms of the two disorders overlap. It’s challenging to identify where one disorder ends and the other begins. In many cases, it’s also difficult to identify which disorder came first, which leads to the question of whether one disorder causes the other, if at all. This leaves therapists to decide which disorder to prioritize when creating a treatment protocol.

Recent research into co-occurring PTSD and SUD sheds light on these questions and offers preliminary answers. Before we discuss the latest data, however, it’s important to understand why PTSD and SUD are related. Briefly: the prevailing opinion is that people with PTSD turn to drugs and/or alcohol in order to alleviate the uncomfortable, life-interrupting emotions and symptoms of PTSD. Alcohol or drug use then becomes their go-to coping mechanism.

This is known as the self-medication theory.

Evidence for the Self-Medication Theory

Mental health scientists engage in a healthy debate about the self-medication theory. Some argue that substance use disorders can increase the likelihood of the development of PTSD, while others cite the following data to support the self-medication hypothesis:

  • People with co-occurring PTSD and SUD who receive SUD treatment only do not show significant improvement in PTSD symptoms.
    • These same individuals are also more likely to relapse
  • People with co-occurring PTSD and SUD who receive PTSD treatment only show significant improvement in PTSD symptoms and SUD symptoms.
    • These individuals are also less likely to relapse

The simple takeaway from this data seems to be that in most cases, PTSD is the primary disorder, and SUD develops after – and sometimes in response to or because of – PTSD. Causality, however, has not been definitively determined, only correlation. Nevertheless, the data are important for two reasons: it helps us understand how to treat adolescents with co-occurring PTSD and SUD, and it helps us understand why a child or adolescent who’s experienced trauma might develop and alcohol or substance use disorder.

Co-Occurring PTSD and SUD: Statistics and Risk Factors

Millions of children and adolescents experience trauma and develop PTSD. Of those, an alarming number go on to develop a substance use disorder in addition to their stress disorder. Evidence from a retrospective cross-sectional study published in 2017 shows the following:

  • The rate of PTSD is five times higher in adolescents with SUD compared to those without SUD.
  • Treatment for adolescents with co-occurring PTSD and SUD is more costly than those with only one or the other
  • Treatment outcomes for adolescents with co-occurring PTSD and SUD are less favorable than for adolescents with only one or the other.

In addition, when compared to individuals with one disorder or the other, individuals with co-occurring PTSD and SUD are more likely to:

  • Develop chronic health conditions
  • Attempt suicide
  • Engage in self-harming behaviors
  • Have difficulty with typical social functioning
  • Engage in violent behavior
  • Have legal problems

It’s clear that a PTSD/SUD dual diagnosis puts an individual at increased risk of developing a host of physical, emotional, and social problems. That’s why getting an accurate diagnosis and pursuing an evidence-based treatment plan is crucial, especially for adolescents. They’re vulnerable to begin with: adolescence is the time during which humans develop coping mechanisms to help manage stress, emotions, and the typical ups and downs of life. An adolescent who’s experienced trauma and then develops an SUD needs help resolving their trauma and learning to cope with their emotions without alcohol or drugs, or the maladaptive patterns may cause impairment that lasts months, years, and in some cases, decades – and that’s not an exaggeration.

Treatment for Co-Occurring PTSD and SUD

Despite the prevalence of co-occurring PTSD and SUD in adolescents, few large-scale studies have been performed to determine the best treatment protocols. The evidence that does exist suggests that an integrated model is the most effective approach: both disorders need to be treated simultaneously for patients to achieve success. To reiterate the data presented above, individuals with a dual-diagnosis – PTSD and SUD – who receive treatment for SUD only do not show significant improvement in PTSD symptoms, while individuals with PTSD and SUD who receive treatment for PTSD only are more likely to relapse than those who receive treatment for both.

Therefore, an integrated model – one that simultaneously treats both disorders – is considered the standard of care for individuals with co-occurring PTSD and SUD. An integrated treatment protocol typically includes an individually tailored combination of the following therapeutic techniques:

Prolonged Exposure Therapy (PE)

Exposure therapy involves exposing – in a controlled, clinician-controlled setting – an individual with PTSD to the thoughts, feelings, emotions, and images they work to avoid. Therapists help patients regain power over these images and emotions, and gradually teach them to experience them without emotional pain or distress.

Cognitive Behavioral Therapy (CBT)

CBT helps people diagnosed with PTSD and SUD identify irrational, life-interrupting patterns of thought and behavior and replace them with patterns of thought and behavior that are healthy and life-affirming. CBT focuses on the present and teaches patients to develop practical strategies to improve their quality of life on a day-to-day basis.

Cognitive Processing Therapy (CPT)

CPT is a formalized derivative of CBT developed by psychiatrists to treat PTSD. Over the course of 12 sessions, patients learn about PTSD in general, identify how PTSD affects their lives, pinpoint their most traumatic experiences, then learn practical techniques to manage their PTSD symptoms. CPT is one of the most highly recommend treatments for PTSD and has been identified as safe and effective in the adolescent population.

Eye Movement Desensitization Reprocessing (EMDR)

According to the American Psychological Association, EMDR is:

“A structured therapy that encourages the patient to briefly focus on the trauma memory while simultaneously experiencing bilateral stimulation (typically eye movements), which is associated with a reduction in the vividness and emotion associated with the trauma memories.”

An interesting fact about EMDR: no one knows how or why it works – but it does work to alleviate the symptoms of PTSD, and no evidence suggests it’s dangerous in any way, for any population.

Medication

In cases where PTSD is accompanied by extreme anxiety, medication may be used to address those symptoms. However, there is little to no evidence regarding the use of medication to treat co-occurring PTSD-SUD.

How to Find Treatment

Parents of teens with a PTSD-SUD dual diagnosis can find the appropriate treatment, and teens can and do learn to manage symptoms of both disorders. With that said, it’s important to know that this particular diagnosis is challenging: evidence suggests parents need to find a therapist or treatment center capable of treating PTSD and SUD concurrently. That’s where the challenge lies: while there are a large number of therapists and treatment centers that excel at treating one condition or the other, there are few with the capability to treat both.

Parents seeking treatment for their teen can start with this psychiatrist finder provided by the American Academy of Child and Adolescent Psychiatry. When searching for a therapist, it’s essential that the therapist has:

  1. Experience in treating adolescent SUD
  2. Experience in treating adolescent PTSD
  3. Knowledge and experience in combining therapeutic modalities to treat co-occurring PTSD and SUD in adolescents
  4. Appropriate licensure, accreditation, and certification

We encourage parents of teens with co-occurring PTSD and SUD to get their teen treatment as soon as possible: the earlier treatment begins, the earlier their teenager can learn to manage their symptoms and live a life of their choosing, rather than one dominated by their co-occurring mental health disorders.