Traumatic Stress and Substance Use Problems
The relation between
substance use and trauma
Research demonstrates a strong link between exposure to traumatic
events and substance use problems. Many people who have experienced
child abuse, criminal attack, disasters, war, or other traumatic
events turn to alcohol or drugs to help them deal with emotional
pain, bad memories, poor sleep, guilt, shame, anxiety, or
terror. People with alcohol or drug use problems are more
likely to experience traumatic events than those without these
problems. Many people find themselves in a vicious cycle in
which exposure to traumatic events produces increased alcohol
and drug use, which produces new traumatic event experiences,
which leads to even worse substance use, and so forth. Just
as traumatic events and substance use often occur together,
so do trauma-related disorders and substance use disorders.
For example, trauma-related disorders, such as post-traumatic
stress disorder (PTSD) and depression, occur frequently among
people with substance use disorders and visa versa. Not only
do trauma-related and substance use disorders wreak havoc
on the person who has them, they also often create major problems
for relationships with family members and friends.
A family doctor, clergy person, local mental health association,
state psychiatric, psychological, or social work association,
or health insurer may be helpful in providing a referral to
an experienced counselor or therapist.
Traumatized people are more likely than others of similar
background to abuse alcohol both before and after being diagnosed
with PTSD. For example:
- One-quarter to three-quarters of people who have survived
abusive or violent traumatic experiences report problematic
alcohol use
- One-tenth to one-third of people who survive accident-,
illness-, or disaster-related trauma report problematic
alcohol use, especially if troubled by persistent health
problems or pain
- Up to 80% of Vietnam veterans seeking PTSD treatment have
alcohol use disorders
- Veterans over the age of 65 with PTSD are at increased
risk for attempted suicide if they experience problematic
alcohol use or depression
- Women exposed to traumatic life events show an increased
risk for an alcohol use disorder
- Men and women reporting sexual abuse have higher rates
of alcohol and drug use disorders than other men and women.
- Compared to adolescents who have not been sexually assaulted,
adolescent sexual assault victims are 4.5 times more likely
to experience alcohol abuse or dependence, 4 times more
likely to experience marijuana abuse or dependence, and
9 times more likely to experience hard drug abuse or dependence.
- Adolescents with PTSD are 4 times more likely than adolescents
without PTSD to experience alcohol abuse or dependence,
6 times more likely to experience marijuana abuse or dependence,
and 9 times more likely to experience hard drug abuse or
dependence.
What are substance use problems?
When people talk about substance abuse, they usually mean
the consumption of alcohol or illegal drugs such as marijuana
or cocaine or the misuse of prescription drugs (using them
in a way that is not how they were prescribed). Substance
use disorders are generally divided into two categories: substance
dependence and substance abuse. Substance dependence is viewed
as more serious than substance abuse and occurs when people
have several of the following problems: (1) they have to take
more of the substance to get the same effect; (2) they suffer
withdrawal when they stop using after long periods of heavy
use; (3) they have difficulty controlling the amount of the
substance they use; (4) they attempt to cut down or stop use
unsuccessfully; (5) they spend a great deal of time trying
to obtain the substance or getting over the effects of use;
(6) they give up important activities or responsibilities
because of substance use; or (7) they continue to use substances
in spite of knowledge that it is harmful to do so.
Substance abuse occurs when substance use results in (1)
major problems with family, friends, at school, or on the
job; (2) being high or intoxicated in situations that are
dangerous (e.g., while driving), (3) problems with the police
due to substance use, or (4) continued use in spite of having
problems with family members about substance use.
The effects of substance use on the
symptoms of traumatic stress
Some of the problems people experience after a traumatic
incident are part of the diagnoses of acute stress disorder
(ASD) and post-traumatic stress disorder (PTSD). ASD describes
experiences of dissociation (e.g., feelings of unreality or
disconnection), intrusive thoughts and images, efforts to
avoid reminders of the traumatic experiences, and anxiety
that may occur in the month following the event. When these
experiences last more than a month, they are described by
the diagnosis of PTSD.
The use of alcohol or drugs can provide a temporary distraction
and relief for traumatized people who may be suffering from
very serious and even debilitating problems across multiple
areas of their lives (thoughts, feelings, bodily experiences,
relationship to self and others, and behaviors). However,
this relief is only temporary, and the use of substances to
reduce symptoms ultimately can be harmful. Substance abuse
reduces a person's ability to concentrate, to be productive
in work and life in general, to sleep restfully, and to cope
with traumatic memories and external stressors. Substance
abuse can increase emotional numbing, social isolation, anger
and irritability, depression, and the feeling of needing to
be on guard (hypervigilance).
Binge drinking or using drugs by a traumatized person may
be a well-intentioned (but ultimately self-destructive) attempt
to "self-medicate" against memories or reminders
of horrific traumatic experiences. It may also help with sleep
problems such as trouble falling or staying asleep, traumatic
nightmares, and constantly being "wound up." Using
substances as a way to self-medicate may help with one problem
but worsen another. For example, substance abuse may temporarily
decrease the severity and the number of frightening nightmares
but may also increase irritability and hypervigilance.
Additional mental or physical health
problems associated with traumatic stress
When a person is experiencing problems with both traumatic
stress and alcohol or drug abuse, he or she will often have
other psychological or physical problems. As many as 50% of
adults with both alcohol use disorders and PTSD also have
one or more other serious psychological or physical problems.
For example, traumatized people who also abuse substances
are often troubled by anxiety disorders (such as panic attacks,
phobias, incapacitating worry or compulsions), mood disorders
(such as major depression or dysthymia), disruptive behavior
disorders (such as attention deficit or antisocial personality
disorder), and multiple addictive behaviors (alcohol abuse,
use of illicit drugs and abuse of prescribed medication).
Physical health problems are also very common among traumatized
people. They are at greater risk for chronic physical illness
(such as diabetes, heart disease, or liver disease) and often
suffer from chronic physical pain, either due to physical
injury/illness or with no clear physical cause.
Treatment for people with traumatic
stress and substance use problems
Substance use problems must be addressed in the treatment
of traumatized people. When substance abuse is or has been
a problem in addition to traumatization, it is best to seek
treatment from an experienced and skilled practitioner who
has special expertise in both substance abuse treatment and
the treatment of traumatic stress.
The initial consultation with a mental health professional
should include questions that sensitively and thoroughly identify
patterns of past and current substance use (alcohol, illicit
drugs, or prescribed medication). Treatment planning should
include a discussion between the treater and the client about
the possible effects of substance abuse problems on trauma-related
problems, including sleep, anger, anxiety, depression, and
work or relationship difficulties. Treatment can include education,
psychotherapy, and support groups that help the client address
substance abuse problems in a manner acceptable to the client.
Treatment for traumatization and substance abuse problems
should be designed as an overall plan that addresses both
sources of difficulty and their interrelationships. Although
there may be separate meetings or clinicians devoted primarily
to traumatization or to substance problems, all interventions
should be carefully coordinated and integrated.
© 2003 International Society For Traumatic Stress Studies.
All rights reserved.
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