Post-Traumatic Stress Disorder, Anxiety Disorders and Substance Use

Nichole Fairbrother, PhD

Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), pp. 27-29

Sadly, many people are exposed to traumatic events such as a motor vehicle accident, rape, assault or other violent crimes, or to natural disasters such as hurricanes or earthquakes. Remarkably, many trauma victims recover and cope well with these events without professional assistance. For the small minority of people who do not recover, post-traumatic stress disorder (PTSD) is the most common diagnosis to develop. PTSD is a form of anxiety disorder that occurs in between one and 14% of the population, at some point in their lifetime, and is more common in women than in men. Many PTSD victims also suffer from depression, substance abuse, and from other anxiety problems.

Not infrequently, we hear the term trauma used in reference to a particular experience. Mental health experts consider a person to have been exposed to a traumatic event if he or she experienced, witnessed, or was confronted with (i.e., learned about) an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of oneself or others. One thing all people with PTSD have in common is they felt intense fear, helplessness or horror during the traumatic event.

The remaining symptoms of PTSD fall into three categories: reliving symptoms, avoidance symptoms and symptoms of increased arousal. While some of these symptoms may be experienced to some extent and at some point by many people not suffering from an emotional disorder, PTSD sufferers experience many of the symptoms below, and find them very upsetting.

Reliving symptoms include:
  • intrusive memories of the event and flashbacks

  • dreams or nightmares about the event

  • acting or feeling as if the event is happening again

  • intense distress and bodily arousal when reminded of the event

Avoidance symptoms include:
  • trying to avoid thoughts, feelings or conversations about the event

  • trying to avoid activities, places, or people that remind one of the event

  • difficulty remembering important parts of the trauma

  • loss of interest and participation in important activities

  • a restricted range of emotions

  • a sense of a foreshortened future

Symptoms of increased arousal include:
  • difficulty falling or staying asleep

  • irritability or outbursts of anger

  • difficulty concentrating

  • hypervigilance (i.e., keeping a close look out for signs of imminent danger)

  • an exaggerated startle response

Post-Traumatic Stress Disorder and Substance Use

Studies examining how PTSD develops have found that a large number of people with PTSD also have problems with substance use. Compared with people who do not suffer from PTSD, people with PTSD are two to four times more likely to suffer from alcohol abuse or dependence, and four to nine times more likely to suffer from drug abuse or dependence.1 Put another way, five to six out of every ten people with PTSD also suffer from substance use problems that interfere with their daily lives and cause additional suffering.

There are several reasons why PTSD and substance use problems often occur together. First, people who abuse alcohol or drugs are often exposed, by virtue of their substance use, to more dangerous situations than people who do not have substance use problems. As a result, they are at greater risk of experiencing the kinds of traumatic life events that may lead to the development of PTSD. Second, some people who develop PTSD may already have problems coping with stress without using alcohol, drugs or other substances. Third, people with PTSD may be vulnerable to using alcohol and drugs as a way of managing their PTSD symptoms (i.e., they are using alcohol and drugs to self-medicate) even if they didn’t have substance use problems before the trauma occurred. For example, a person with PTSD may drink or use drugs to stop the scary memories or lower the uncomfortable body sensations of anxiety. Unfortunately, substance use often makes these symptoms worse in the long run and is not a recommended coping strategy.

Researchers have found that people who develop a substance use problem after a traumatic event often experience unmanageable anxiety. People with PTSD and substance use problems often believe their anxiety symptoms mean they are going ‘crazy,’ dying or will never be the same person they were before the trauma.1

It is very important that people coping with PTSD and substance use problems receive treatment or the symptoms can become chronic and even worsen over time. People who suffer from both substance use problems and PTSD do not respond well to traditional treatment for substance use problems. However there is strong reason for hope, as people who receive a combined PTSD and substance use treatment experience significant decreases in their symptoms.1 Greater access to treatments that are designed specifically for people coping with both PTSD and substance use problems is needed in BC.

Effective treatments often include learning new ways of coping that do not involve the use of drugs or alcohol. Effective treatments also help the person deal with the traumatic event so that the upsetting memories and associated symptoms no longer get in the way of living a full and rewarding life. It is also important to validate the experiences of people suffering from these two disorders, and to help them understand why these problems are both occurring. This is especially important because many people may be unaware they have both problems. (For more information on approaches to dealing with these issues, please see the article by Nancy Poole on the following page).

Substance Use and Other Anxiety Disorders

While PTSD and substance use are very commonly found together, people with other forms of anxiety disorders also experience problems with substance use. Substance use disorders and several types of anxiety disorders occur together at a very high rate.2,3 People suffering from an anxiety disorder are more likely to have problems with alcohol use than people without an anxiety disorder.2 For example, people with generalized anxiety disorder or panic disorder are three times as likely to suffer from a substance use disorder over the course of their lifetime compared to people who do not have an anxiety disorder.2 Interestingly, there is not a high level of substance use in people who suffer from obsessive-compulsive disorder.2

More research is needed for us to better understand why anxiety disorders are associated with a higher rate of substance use disorders. We really don’t know if having an anxiety disorder makes a person more vulnerable to abusing substances or if the reverse is true: that having a substance use disorder makes people more vulnerable to developing an anxiety disorder. It may also be that some other issue such as low social support or social isolation makes people vulnerable to both.

We do know that alcohol, at least initially, can help to dampen some of the symptoms of anxiety. However, over the long term, it may actually help to maintain the anxiety problem. Because, in the short run, alcohol consumption helps to reduce feelings of anxiety, substance use is reinforced and people can end up in a vicious circle of anxiety and dependence. We also know that people with anxiety disorders and people with substance use problems both tend to be fearful of the bodily arousal that typically accompanies anxiety (e.g., rapid heart, difficulty breathing, etc.), and believe that these sensations of arousal are dangerous in some way (physically, psychologically or socially). It may be that, compared to people who are not very afraid of the bodily arousal that accompanies anxiety, people who are fearful of these sensations experience a greater reduction in bodily sensations of anxiety when they drink or use certain kinds of drugs.3 If this is the case, it may help to explain why anxiety problems and substance use problems often occur together.

Many people with an anxiety disorder and a substance use disorder get the best results when they learn new ways of managing both problems. If you have an unmanaged anxiety disorder, it may be very difficult to overcome your problems with substance use (and vice versa). Fortunately there are a growing number of effective treatment approaches that target both anxiety and substance use problems. People with anxiety disorders and substance use problems can overcome these difficulties.

 
About the author

Nichole is the Community Liaison Officer for the Anxiety Disorders Association of BC and an honourary Research Associate with the Anxiety Disorders Unit in the Department of Psychiatry at the University of British Columbia

Footnotes:
  1. Conrod, PJ, & Stewart, SH. (2003). Experimental studies exploring functional relations between post-traumatic stress disorder and substance use disorders. In P. Ouimette & P. Browns (Eds.), Trauma and Substance Use: Causes, consequences, and treatment of comorbid disorders (pp. 29-55). Washington, DC: American Psychological Association.
  2. DeHaas, RAB, Calamari, JE, & Bair, JP. (2002). Anxiety sensitivity and the situational antecedents to drug and alcohol use: An evaluation of anxiety patients with substance use disorders. Cognitive Therapy and Research, 26, 335-353.
  3. Stewart, SH, & Kushner, MG. (2001). Introduction to the special issue on 'Anxiety Sensitivity and Addictive Behaviors.' Addictive Behaviors, 26, 775-785.
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