is related to increased odds of traumatic experiences, which then initiate the development of PTSD (Hawn et al., 2020). Another suggestion is that chronic substance use may inhibit a client’s psychological fortitude in a way that intensifies PTSD symptom severity (Berenz & Coffey, 2012; Roberts et al., 2015). While the vulnerability hypothesis has primarily focused on how substance use may increase the risk of trauma, trauma exposure may also increase the likelihood of substance use due to the impacts of trauma on brain regions associated with emotion regulation, reward behaviors, decision making, and impulsivity (Garami et al., 2019). Additionally, there is evidence that shows the effects of stress on the HPA axis may increase the reinforcing effects of drugs (Moustafa et al., 2021). A third possibility is that PTSD and substance abuse share the same etiological factors. This explanation draws on research that suggests PTSD and substance use share common risk factors, such as certain personality traits, impulsivity, externalizing/internalizing behaviors, and common environmental factors (Hawn et al., 2020). Furthermore, individuals with emotional regulation deficits and avoidant coping tendencies are at risk for elevated symptom presentation in both PTSD and substance use disorder (Roberts et al., 2015). According to this model, PTSD and substance use disorder would be occurring as simultaneous but independent disorders (Berenz & Coffey, 2012; Roberts et al., 2015). Regardless of etiological origins, however, substance use and PTSD are interconnected (NCPTSD, 2020), and individuals with both disorders experience bidirectional effects that initiate a vicious cycle of suffering (Hawn et al., 2020). For instance, the physiological symptoms of withdrawal can trigger PTSD symptoms, such as irritability, which may deplete coping resources and result in relapse. Berenz and Coffey (2012, p. 472) reviewed multiple research Traumatic Brain Injury The experiences of veterans of the wars in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom) have led to a heightened awareness of the ubiquity of traumatic brain injuries (TBIs) occurring alongside PTSD (Bahraini et al., 2014). Veterans have played an important historical role in the understanding of PTSD. Veterans from these particular wars, rife with improvised explosive devices (IEDs), demonstrated the need for special consideration of comorbid TBIs. The rates of comorbid PTSD and TBI range from 3% to 40% across various studies (Alway et al., 2016). Bahraini and colleagues (2014, p. 60) offer a rationale for understanding the link between TBIs and PTSD: “Unlike other psychiatric disorders, PTSD is unique, in that its onset is tied to a discrete event, namely a psychologically traumatic stressor. Second, brain injuries resulting from biomechanical trauma are frequently sustained in the midst of psychologically traumatic experiences.” A TBI is defined as an injury to the brain that affects how the brain works (e.g., resulting in loss of consciousness or altered mental status; Centers for Disease Control and Prevention [CDC], 2022). It is important to note that a TBI can occur even if there is no direct contact with the head (NCPTSD, 2022). The severity of a TBI can range from mild to severe, depending on the symptoms. Although there are a multitude of definitions across organizations, a mild TBI is primarily categorized by a loss or alteration of consciousness for less than 30 minutes and loss of memory for less than 24 hours, an impaired mental state at the time of the accident, and transient neurological deficit (Lefevre-Dognin et al., 2021). If the symptoms persist for an extended period of time and neurological deficits do not subside, the TBI
studies demonstrating that “when symptoms of one condition worsen, symptoms of the other condition worsen. Likewise, when symptoms of one condition improve, symptoms of the other condition improve.” Case Example Carolynn, an army veteran, had returned from two combat tours in Iraq with intense PTSD symptoms. She believed that posttraumatic stress was a byproduct of military service and that seeking treatment would represent weakness. Some of her friends suggested that “talk therapy is useless; they can’t relate to us and what we’ve been through,” so she decided to manage her symptoms on her own. Carolynn was frequently triggered throughout the day, when she was in her car (she had witnessed a convoy explosion), yet she needed to drive to appointments and job interviews. She started drinking alcohol to calm her nerves when in the car, slowly increasing her alcohol intake over a few months. Carolynn was eventually cited for driving under the influence of alcohol and was mandated by Veterans Court to receive substance abuse treatment. Though Carolynn was genuinely working on her recovery, any time she went two days without drinking, her withdrawal symptoms would compound her PTSD symptoms and she would become irritable and angry, unable to perform in her job interviews. Each time this happened, she would decide to have just a little alcohol to temper the withdrawal, and the lapse would snowball into a full relapse. Eventually, Carolynn decided to put the job search on hold while she got past the acute withdrawal symptoms, drawing on new coping strategies she had gained in therapy. Once she got past the withdrawal, she was able to continue her substance abuse treatment, which allowed her to gain a different perspective and give herself permission to seek treatment for her PTSD without fear of stigmatization. would be considered moderate or severe (NCPTSD, 2022c). Approximately 80% of TBIs in nonmilitary populations are mild (NCPTSD, 2022c). There are a range of causes and symptoms associated with TBIs. The main causes of TBIs in the general population are motor vehicle crashes, falls, and physical assaults (Alway et al., 2016). Main causes differ for the military population, where blasts, motor vehicle crashes, and gunshot wounds are the main culprits (NCPTSD, 2022c). Individuals suffering from TBIs may exhibit cognitive deficits, impaired memory, insomnia, dizziness, headaches, irritability, sensitivity to noise and light, and somatic and affective problems (Bahraini et al., 2014; NCPTSD, 2022c). The majority of people who have a mild TBI will be back to normal within three months without any special treatment (NCPTSD, 2022c), however, in some cases, symptoms are sustained. Practitioners face challenges in discriminating between PTSD and TBI symptoms. By nature of the memory impairments of TBI, some individuals do not recall even experiencing a head injury, so practitioners may not have the needed criteria to diagnose co-occurring TBI. Also, self- reported TBI symptoms may be vague, and can therefore be confused with PTSD symptoms. For instance, reports of dizziness or headaches could easily be viewed as indirect effects of PTSD symptoms (Summerall, 2017). Diagnostic false positives between PTSD and TBI are also common. Individuals with TBI may meet criteria for PTSD, and some PTSD symptoms get misdiagnosed as TBI symptoms (Alway et al., 2016; Summerall, 2017). This problem likely results from the overlap between PTSD and TBI symptoms, such as irritability, disturbances in memory, and difficulties with concentration and sleep (Summerall, 2017).
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