How is Trauma Related to Addiction?

The Relationship Between Trauma-Related Disorders and Substance Use Disorders

Trauma-related disorders, such as Post-Traumatic Stress Disorder (PTSD), are often closely linked with Substance Use Disorders (SUDs). The interplay between these conditions is complex, involving multiple factors such as using substances to self-medicate trauma symptoms and substance use increasing the risk of developing PTSD. Understanding this relationship is crucial for recovery and providing effective, integrated treatment approaches.

Using Substances to Medicate Trauma Symptoms

Individuals with trauma-related disorders, such as PTSD, may turn to substances like alcohol, marijuana, opioids, or stimulants to self-medicate their symptoms. This is often an attempt to numb emotional pain, reduce anxiety, escape from intrusive memories, or improve sleep. While substances may provide temporary relief, they often lead to increased dependence, tolerance, and withdrawal symptoms, which can worsen PTSD symptoms and create a cycle of addiction.

Substance Use Predisposing a Person to Developing PTSD

Conversely, substance use can increase an individual’s risk of experiencing traumatic events that may lead to PTSD. For example, heavy alcohol or drug use can result in impaired judgment and risky behaviors, increasing exposure to violence, accidents, or assault. In these cases, the substance use disorder precedes the trauma, creating a dual challenge of treating both the SUD and the resulting PTSD.

Underlying Neurobiology: PTSD and SUD Dysregulate the Amygdala and Weaken Prefrontal Cortex Functioning

Both PTSD and Substance Use Disorders (SUD) significantly impact brain function, particularly by dysregulating the amygdala and weakening the prefrontal cortex. These changes reinforce the symptoms of both disorders and complicate the recovery process.

  • Amygdala Dysregulation: The amygdala, a region of the brain associated with processing emotions and detecting threats, is often hyperactive in individuals with PTSD and SUD. In PTSD, the amygdala becomes overly sensitive due to repeated exposure to trauma-related cues, leading to heightened fear responses, hypervigilance, and anxiety. In SUD, the amygdala becomes conditioned to respond intensely to substance-related cues, triggering cravings and compulsive drug-seeking behaviors. During withdrawal from substances, the dysregulation of the amygdala contributes to unpleasant mood, anxiety, and agitation. The combined impact of PTSD and SUD creates a cycle where both trauma-related and substance-related cues lead to an overactive stress response, perpetuating both conditions.

  • Weakened Prefrontal Cortex Executive Functioning: The prefrontal cortex (PFC) is responsible for executive functions such as decision-making, impulse control, and emotional regulation. Both PTSD and SUD are associated with reduced activity and connectivity in the PFC, impairing an individual’s ability to regulate their emotions, control impulsive behaviors, and make sound decisions. In PTSD, this weakened PFC functioning contributes to difficulties in distinguishing safe from threatening situations and in regulating intense emotions. In SUD, it undermines the ability to resist cravings and make decisions that promote recovery. When these conditions co-occur, the dual impairment of the PFC further complicates treatment adherence and recovery efforts, as individuals struggle with both trauma symptoms and addiction-related impulses.

The dysregulation of the amygdala and weakening of the PFC create a neurological loop that reinforces the symptoms of PTSD and SUD, making integrated treatment approaches essential for effective recovery.

Definition of a Substance Use Disorder (SUD)

A Substance Use Disorder (SUD) is a chronic, relapsing condition characterized by the compulsive use of substances despite harmful consequences. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), SUDs range from mild to severe, depending on the number of criteria met, such as inability to control use, continued use despite problems, tolerance, and withdrawal symptoms.

SUD Symptoms and Diagnostic Criteria

The DSM-5 outlines 11 criteria for diagnosing a Substance Use Disorder. These include:

  1. Taking the substance in larger amounts or for longer than intended.

  2. Wanting to cut down or stop using the substance but being unable to.

  3. Spending a lot of time getting, using, or recovering from substance use.

  4. Craving or a strong desire to use the substance.

  5. Failing to fulfill major role obligations at work, school, or home due to substance use.

  6. Continuing to use despite social or interpersonal problems caused by substance use.

  7. Giving up important social, occupational, or recreational activities because of substance use.

  8. Using substances in physically hazardous situations.

  9. Continuing use despite physical or psychological problems related to substance use.

  10. Developing tolerance (needing more of the substance to get the same effect).

  11. Experiencing withdrawal symptoms when not using the substance.

Risk and Protective Factors for SUD

Risk Factors:

  • Genetic predisposition

  • Childhood trauma and adverse experiences

  • Mental health disorders, including PTSD, anxiety, and depression

  • Peer pressure and social environment

  • Easy access to substances

Protective Factors:

  • Strong support network

  • Healthy coping mechanisms for stress

  • Access to mental health care and therapy

  • Stable home environment

  • Engagement in meaningful activities

Comorbidity Rates with PTSD

The co-occurrence of PTSD and SUD is common. Research shows that up to 60% of individuals with PTSD also meet the criteria for a substance use disorder. This comorbidity complicates the clinical picture and often requires integrated treatment approaches that address both disorders simultaneously.

Evidence-Based Treatments for SUD

Effective treatment for SUD often involves a combination of behavioral therapies, medications, and support systems:

  • Cognitive Behavioral Therapy (CBT): Helps clients recognize and change problematic thoughts and behaviors related to substance use.

  • Motivational Interviewing (MI): Encourages individuals to find and harness their motivation to change substance use behaviors.

  • Medications: Depending on the substance, medications like methadone, buprenorphine, naltrexone, and disulfiram may be used to reduce cravings and prevent relapse.

  • 12-Step Programs and Support Groups: Provide community support and accountability.

  • Integrated Treatment for Co-Occurring Disorders: Combines therapies for both PTSD and SUD, such as Trauma-Informed Care and Seeking Safety, which focuses on coping skills without using substances.

  • Appropriate Level of Care: The American Society of Addiction Medicine (ASAM) established a level of care system to match a client’s needs with an appropriate level of support. From highest to lowest, these include: medical detoxification, 4 levels of residential services (RTC), partial hospitalization programs (PHP - day treatment), intensive outpatient programs (IOP), outpatient, and early intervention levels of care. Every licensed addiction treatment provider will fall into one of these categories or a similar category depending on their state requirements.

Signs That Medical Detox is Required

Medical detox may be necessary when an individual shows signs of severe withdrawal symptoms, such as:

  • Tremors, seizures, or hallucinations

  • Extreme agitation or anxiety

  • Nausea, vomiting, or diarrhea

  • Dangerously high blood pressure or heart rate

  • History of severe withdrawal complications

Medical detox involves monitoring and managing withdrawal symptoms in a controlled environment to ensure safety and comfort. Stopping the prolonged and heavy use of alcohol and benzodiazepines should always be addressed by a medical professional due to the risk of life threatening seizures and other medical complications. When in doubt, seek medical guidance. 

Recovery Rates for SUD When Comorbid with PTSD

Recovery rates for individuals with comorbid PTSD and SUD vary, but integrated treatment approaches have shown promise. Studies indicate that combining trauma-focused therapies (like EMDR or Prolonged Exposure Therapy) with SUD treatments can lead to significant improvements, with recovery rates ranging from 30-50% for those who complete treatment. However, recovery is a long-term process that often involves ongoing support and multiple treatment episodes. In general, national surveys show that the majority of people (72%) who report ever having a substance use disorder report they are now in recovery, giving hope that over time most people make progress and improve their lives. 

Integrated Treatment Strategies for SUD and PTSD

In the past, clinical folklore suggested that trauma therapy should be avoided for people in treatment for SUD due to concerns it would induce too much stress, cause treatment drop out, or relapse. Since then, research has been conducted on multiple treatments for people with SUD and PTSD, with 3 showing effectiveness at reducing PTSD symptoms while having negligible negative effects on the course of SUD treatment. While some treatments show some cross over effects that benefit the SUD recovery process, this is still inconclusive and not thoroughly demonstrated. A current study is underway that may give us better answers as to what treatments are most effective together and at what point in the recovery process. Current research suggest the following treatments can be safely incorporated into an overall strategy for SUD recovery:

Prolonged Exposure Therapy (PE): PE is the most researched trauma focused therapy to be combined with SUD treatment and has shown to greatly reduce PTSD symptoms compared to SUD treatment as usual, but the positive impact on SUD recovery is less apparent. These studies caused the field to reconsider previous notions that trauma should not be addressed during SUD treatment in favor of the integrated approach.

Cognitive Processing Therapy (CPT) and Eye Movement Desensitization Reprocessing Therapy (EMDR): both of these therapies have shown similar results to PE in preliminary research but more research is needed.

It currently appears that adding an evidence based trauma therapy that already shows benefit for PTSD to the SUD recovery process effectively addresses PTSD while having minimal negative impacts on SUD recovery. This has alleviated previous fears that trauma therapy would cause people with SUD to relapse or drop out of treatment. Over time, it may be shown that living without PTSD symptoms serves as a protective factor against relapse as one would logically conclude.

Conclusion

On their own, SUD and PTSD are both challenging to recover from, often requiring a lot of support and assistance from specialized professionals. When they occur together, the situation becomes further complicated. This highlights the importance of working with professionals who have expertise in both areas. Coordinating the right treatment strategies in the right sequences so both trauma and substance use are being addressed is essential for optimizing the recovery process. As a counselor who is licensed in both areas, and a person in recovery myself, I take an empathetic and non-judgmental stance toward substance use while recognizing the seriousness of it’s impact. I’m optimistic when it comes to recovery - I know it’s possible and have seen countless people completely transform their lives. But I’m keenly aware of the way substance use can interfere with therapy and the difficulty in getting it stabilized. I share my observations honestly and directly while giving my clients the autonomy to choose how to proceed based on my feedback. I’m always happy to assist with coordinating additional care when necessary.

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