He had worked hard to suppress the memories, and although he was able to avoid thinking about his traumas during the day, intrusive memories would often creep into his dreams, impacting his sleep. Chris reported that he felt hyperarousal throughout the day, which was likely contributing to his fatigue; he stated, “my alarm system is on all day long, and just drains Substance Use Substance use often co-occurs with PTSD, with approximately half of individuals with a current diagnosis of substance use disorder (SUD) meeting criteria for PTSD (Berenz & Coffey, 2012; National Center for PTSD [NCPTSD], 2020). The presence of substance use among individuals with PTSD is higher for men than for women, and it is particularly pronounced in combat veterans (Roberts et al., 2015). Among the various forms of substance use disorder, alcohol use disorder is the most common PTSD comorbidity (Roberts et al., 2015). PTSD may exacerbate substance use disorder symptoms, lower general functioning, and stall recovery (Roberts et al., 2015). Individuals with comorbid PTSD and substance use disorder exhibit greater drug use severity, more intense cravings, and more frequent episodes of relapse; they also show poorer treatment outcomes than individuals with only one of the two disorders (Berenz & Coffey, 2012). Although for many people the challenges with substance use are initially targeted for therapy due to worry that deeper trauma processing may trigger relapse, several studies have shown that concurrent treatment to address PTSD and SUD does not lead to an increase in symptoms and is more effective than treating substance use alone (Back et al., 2019; Tripp et al., 2019). However, one study found that individuals who experienced trauma at an earlier age showed less improvement in substance use as a result of treatment and may need additional specialized treatment (Fitzpatrick et al., 2020). The two primary causal models employed to explain PTSD and substance use comorbidity are the self-medication hypothesis (i.e., PTSD causes substance use) and the vulnerability hypothesis (i.e., substance use increases the risk for trauma). Research most strongly supports the self-medication hypothesis; however, there have been critiques raised as to the strength of studies that examine this model (Hawn et al., 2020). This theory suggests that individuals with PTSD rely on drugs or alcohol as a symptom management strategy in order to cope with psychiatric distress (e.g., intrusive traumatic memories) or to experience symptom relief through a numbing effect (Berenz & Coffey, 2012; Hawn et al., 2020; Roberts et al., 2015). Eventually, the PTSD and self-medication cause substance use disorder and/or chemical dependence. Multiple research studies have demonstrated that individuals with PTSD and co-occurring substance use experience increased cravings “in response to personalized trauma cues and PTSD symptoms” (Berenz & Coffey, 2012, p. 472). Another explanation for the relationship between substance use and PTSD is that preexisting substance use increases the risk for PTSD. One possibility is that substance use 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 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
my battery.” Therapeutic work focused on acutely treating some of his somatic symptoms and then engaging in deeper traumatic processing. Chris was able to build up to the trauma narrative, slowly desensitizing himself rather than suppressing his emotions and memories, which reduced his hyperarousal and led to general symptom relief. 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 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.
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.
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