Post-traumatic stress disorder (PTSD) occurs as a response to experiencing, witnessing, or hearing about a very traumatic and stressful event. The individual diagnosed with PTSD must directly or indirectly be involved in the experience of a specific type of traumatic event. Traumatic events that can be associated with PTSD include:
- Stressful combat experiences
- Physical assaults, either attempted or completed
- Rape, either attempted or completed
- Physical or sexual abuse
- Accidents, such as an automobile accident
- Terrorist acts, natural disasters, and kidnapping attempts
- Being diagnosed with a serious illness
The individual does not actually have to be directly involved in these potential stressful and traumatic experiences. There are several different modes of involvement that can be associated with the development of PTSD, such as:
- Direct involvement in the occurrence or event
- Being a witness to the event as it happens to other people
- Repeated exposure to the aftermath of such events (e.g., The most common examples are first responders who respond to crime scenes or natural disasters.)
- Learning that a traumatic event has happened to a loved one
The notion of direct and indirect involvement and the definition of what actually qualifies as a traumatic event make it quite possible for a number of seemingly innocuous occurrences to be potential triggers of PTSD. There is quite a bit of room for interpretation when deciding if an individual has actually developed PTSD; therefore, PTSD can only be diagnosed by a licensed mental health professional. Nonetheless, there is a relatively consistent symptom pattern that occurs in individuals who develop PTSD. The symptoms of PTSD include:
- Lucid re-experiences or recollections of the event
- Having strong anxiety associated with reminders of the event
- Attempts to avoid stimuli that remind the person of the event
- Feeling detached from others
- Feeling detached from reality (feeling as if things are not real)
- Being unable to feel pleasure.
- Consistently lacking motivation to do things
- Ongoing dysphoria (negative emotions)
- Mood swings
- A pessimistic attitude regarding oneself, the world, and the future
- Experiencing suspiciousness
- Having difficulty displaying emotions
- Constantly isolating oneself from other people
- Having difficulty recalling specific aspects of the traumatic event
- Problems with memory, attention, and other cognitive processes
- Engaging in self-harm behaviors or feeling suicidal
- Engaging in self-destructive behaviors, such as substance abuse
- Being hypervigilant that certain things that are reminiscent of the event will re-trigger the experience of it
The above symptoms do not represent the specific diagnostic criteria used by clinicians to diagnose PTSD, but represent a number of symptoms that are part of the overall diagnostic criteria. The diagnosis is made on the number of symptoms an individual experiences within a specific timeframe. There is the possibility that individuals who eventually develop PTSD will initially experience a disorder termed acute stress disorder, which is a disorder that resembles PTSD but is not as intense.
A full PTSD syndrome may develop soon after the traumatic event, or it may take months to even years for the syndrome to develop. In addition, young children can also develop PTSD. The diagnostic criteria for children 6 years old or younger is slightly different than the diagnostic criteria applied to adults.
Risk Factors for the Development of PTSD
As stated, one must be directly or indirectly involved in some potentially traumatic event to be diagnosed with PTSD. So the primary risk factor for the development of PTSD is being directly or indirectly involved in some potentially stressful traumatic event. Given that, it is impossible to predict who will develop PTSD after a traumatic event.
There are a number of different risk factors identified from research studies that indicate that certain variables are associated with a higher risk to develop PTSD following the experience of trauma. It is important to understand that risk factors are not determinants that guarantee that any individual will develop the disorder or will react in a specific manner to trauma; they are simply associated with an increased potential to develop a disorder under the right conditions. Obviously, this risk increases if one has multiple risk factors.
Substance Use Disorders and PTSD
There are numerous research studies that have observed that individuals with PTSD are also significantly more often diagnosed with substance use disorders than individuals in the general population. The figures indicate that up to 20 percent of individuals seeking treatment for PTSD may also have a substance use disorder. In addition, individuals with PTSD who display certain symptoms may be more likely to present with a co-occurring substance use disorder. These symptoms include flashbacks and other intense symptoms where the individual re-experiences the trauma, such as nightmares or intrusive thoughts. Thus, there is some evidence that the symptom severity of PTSD may be associated with a greater potential to abuse certain substances.
PTSD can be associated with any specific type of substance use disorder, but it appears that alcohol, opioid drugs, anti-anxiety drugs, cannabis, and cocaine may be more likely abused in individuals with PTSD. Many of these individuals may engage in polydrug abuse.
The relationship between substance use disorders and PTSD is quite complicated and does not always fit in with the common notion of a self-medication model where an individual with PTSD begins using substances to self-medicate PTSD symptoms.
In fact, a salient risk factor to develop PTSD is having a substance use disorder before experiencing trauma, and having a history of substance abuse is also related to the severity of one’s PTSD.
It is far more likely that psychological disorders, such as PTSD and substance use disorders, share certain characteristics that indicate that people who are vulnerable to one of these disorders also have an increased vulnerability to the other. This is often known as the shared liability model or shared factors model. These shared factors can be environmental factors, such as a history of abuse or having a history of limited resources, or they can be biological factors, such as the different disorders having similar genetic associations and/or similar neurobiological mechanisms that are associated with their development.
The shared liability model is most relevant in understanding PTSD when it is assumed that a combination of environmental factors and inherent factors work together to increase the risk to develop different psychological disorders, and that these factors can interact to increase the potential to develop co-occurring disorders.
The best option to treat an individual who has PTSD and a co-occurring substance use disorder is to treat both disorders at the same time. It is generally considered inappropriate to address one disorder and ignore the other in cases where it is known that an individual has a psychological disorder and a co-occurring substance use disorder. Research has also indicated that treating only one disorder will not result in a successful outcome.
The treatment options for individuals with PTSD and a co-occurring substance use disorder are dependent on the severity of both. For example, an individual who has a substance use disorder associated with physical dependence will need to engage in some formalized medical detox program initially to deal with the inevitable withdrawal symptoms that will occur. A detox program is only the first step in recovery from both disorders.
Treatment should be undertaken by a team of trained professionals who can address both disorders from a number of different angles and assist in the development of a treatment plan that is based on empirically validated treatment techniques and is individualized for the specific needs of the client. This typically includes:
- Participation in 12-Step groups
- A long-term aftercare program
- Family support and/or family therapy if needed
- Focused therapeutic interventions for both substance abuse and PTSD
- Group, individual, or a combination of group and individual treatments
- Initial inpatient treatment or sustained outpatient treatment, depending on the needs of the individual
- Medical management for psychological issues, issues associated with withdrawal from substance abuse, and for other medical problems
PTSD is a severe psychological disorder that often presents with a comorbid substance use disorder. There are a number of different factors that may interact to determine the severity of both one’s PTSD and substance abuse issue. Because there is a strong association between having PTSD and the development of substance abuse, any individual suspected of having PTSD should also be thoroughly screened for a substance use disorder (as well as any other psychological disorder). Treatment should address both disorders together and should be performed in a comprehensive manner using as many appropriate resources as possible.