A person who has a dual diagnosis (also referred to as co-occurring disorders) has two separate illnesses, which need to be treated simultaneously.
On a clear day in April 2013, thousands of people gathered in Boston for a celebration of endurance and athleticism. Some of them planned to run the grueling Boston Marathon course, while others came to cheer them on.
Some may have expected muscle pain, cramping, or soreness. None expected what really happened.
Two bombs exploded just 12 seconds apart, and smoke filled the sky. People described scenes of horror with blood, screaming, and chaos.
By the end of that day, three people died. Scores were injured, and some lost their limbs.
Some of those injuries were visible. Bits of metal twisted into flesh, causing bleeding and broken bones. But some of those injuries were invisible. People began replaying the events over and over in their minds. They couldn’t sleep or eat or enjoy their favorite activities. You couldn’t see them hurting, but their pain was real.
The Anxiety and Depression Association of America says 67 percent of those exposed to an episode of mass violence, like the bombing in Boston, develop post-traumatic stress disorder (PTSD). Those who do often use drugs and alcohol to cope with the pain.
Adding substance abuse to an existing mental illness is akin to pouring gasoline on a campfire. Rather than helping, it causes more harm. Treatment programs work like a fire blanket, putting out the damaging flames and helping to restore balance.
How Does PTSD Develop?
PTSD is a disorder of reverberations. A traumatic event happens, the brain changes, and symptoms emerge.
We’re surrounded by trauma throughout our lives. In fact, PTSD United says that 70 percent of American adults have lived through at least one traumatic event. That could involve any of the following:
- Car crashes
- Natural disasters
- Serious illnesses
- Sudden losses
- Terrorist activities
- Military deployment
These events are very different. Some involve a moment of choice, in which you decide to place yourself at the center of a conflict. Others are completely unexpected, and they take hold without warning.
But all the triggers in this list have one thing in common. In each situation, there’s an element of intense fear. You may feel that your life is ending, or you may fear for the life of someone you love. That powerlessness over the future is at the core of trauma.
While almost everyone lives through an event like this, PTSD United says only 20 percent of people emerge from trauma to develop PTSD.
PTSD can’t be diagnosed with a brain scan or blood test. Instead, doctors look for a cluster of symptoms that persist for a month or longer. The signs include:
- Unwelcome thoughts. Your daily life is punctuated with vivid, unavoidable memories of the event. And when you fall asleep, you may dream about what happened. These memories feel real, and often, they’re terrifying.
- Avoidance. To escape from your memories, you may shy away from reminders of the event. People, places, smells, and sounds are triggers, and when you’ve had a flashback in one situation, you’ll do all you can to avoid a repeat.
- Self-blame. You replay the event in your mind, and you feel guilty or ashamed about how you felt or the decisions you made. Your inner voice grows negative, and you tell yourself you’re worthless or bad.
- Reactivity. You explode with anger or tears in situations that seem benign or routine. You push others away, and you grow even more isolated and angry. Reckless behavior increases.
Symptoms can intensify, and sometimes, they persist. The American Psychiatric Association says some people struggle with these unusual thoughts and feelings for years.
For some, those symptoms are minor. But for others, they are so intense and persistent that they interfere with daily life. The National Institute on Mental Health says about 36 percent of people with PTSD have symptoms doctors would consider “serious.”
PTSD Risks Higher in Some Groups
Pain follows trauma, and that’s always been true. Ancient writers like Homer and Shakespeare told us stories about damaged warriors and grieving parents and the terrible choices they made to ease the ache. But our understanding of PTSD has deepened with time, and as a result, we know a lot more about who gets this disorder and why it might happen.
Before 1980, doctors referred to classic PTSD as “shell shock,” and it was deemed part of a soldier’s experience. The things men saw on the battlefield changed them, and they returned home unable to handle daily life.
In the 1980s, PTSD was officially recognized as a disorder with specific, measurable symptoms. It was described in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, and that meant doctors could both spot and treat the issue in any patient, and they could bill for their time.
Diagnosing a patient means creating data, and researchers began scouring the numbers to determine how often this problem happened and whom it happened to. They discovered that PTSD risks are higher in:
- Women. About half of all women experience trauma, says the U.S. Department of Veterans Affairs, and it’s often a sexual event. Women react to these violations just as soldiers react to war.
- Repeat survivors. Living through more than one traumatic episode increases the risk of PTSD.
- Soldiers. War is inherently traumatic, but the Anxiety and Depression Association of America points out that soldiers also endure head injuries that can contribute to PTSD.
- Families. Some research suggests that PTSD can be passed from parents to children through DNA, although more work must be done to tease out the responsible genes.
No matter how it develops, the disorder can be damaging. For some, the solution seems to lie within pills, powders, and drinks.
Self-Medicating With Substance Abuse
Imagine if you could pop something into your body and make all your pain go away? For someone living with PTSD, alcohol or drugs can seem like reasonable solutions to difficult problems. It’s a choice many people make, and the consequences are dire.
The PTSD Alliance says about half of the people who have PTSD abuse alcohol, and those with PTSD are three times as likely to use drugs as those who don’t have the disorder.
For someone with PTSD, these substances are appealing because they:
- Numb. Sedating drugs quiet an overactive, frantic mind.
- Sedate. PTSD interrupts deep sleep, and even when fatigue sets in, it’s hard to rest. Some drugs slow down the central nervous system, resulting in a sleep-like state.
- Enhance. Depression breaks emotional ties. Some drugs release chemicals that boost a sense of emotional connection.
- Excuse. It’s hard to explain how PTSD feels. Drugs and alcohol abuse is easier to understand. Blaming symptoms on substances can reduce the need for conversation.
For someone with PTSD, the goal isn’t simple alteration. Obliteration is the ultimate reward.
According to the U.S. Department of Veterans Affairs, war veterans with PTSD tend to drink in a binge pattern. They take in four to five alcoholic beverages within about two hours, hoping to change their consciousness completely.
Unfortunately, substances wear off. The liver clears alcohol away, and the kidneys process drugs. When sobriety returns, all of those avoided feelings come to the fore, and often, they’re stronger than they were before.
The person has a choice: to deal with the feelings or to use bigger doses of substances to bury them again.
Each time the cycle repeats, the addiction strengthens. In time, physical dependence forms and people are unable to function without substances. Their ignored feelings are so strong that they’re impossible to handle without help.
Researchers think the damage done by PTSD makes the brain more vulnerable to addiction. In one study with rats, a repeated foot shock led to lingering in an area where drugs were given. These rats had brains with unusual chemical signals too, so they found the drugs very rewarding. Ultimately, the trauma of the shock led to them experiencing more rewarding effects from the drugs.
In a second rat study, researchers found brain abnormalities that seemed to make the rodents more susceptible to both PTSD and substance abuse. Those same changes could, the researchers said, make drugs more enticing.
These studies are very intriguing, as they seem to suggest that there’s something unusual going on in the brains of people who have PTSD, and that difference could make the addition of drugs incredibly dangerous. But rats aren’t people, and similar studies haven’t been done with human models.
What the research does suggest is that people with PTSD who use drugs are placing themselves in danger, and they may not be able to cope without help.
The Foundation of Treatment
Therapists once thought of PTSD and addiction as two separate problems. Each deserved respect, and each needed its own type of care. Now, we know that these are intertwined concerns and that recovery works best when it runs on parallel tracks.
For example, PTSD is often addressed with exposure therapy. It can take many forms, but treatment typically involves revisiting distressing memories while in a safe space. People attempt to remember every detail, and they discuss their feelings about what happened. Therapy helps to bring the negative images to the surface, so they stop bubbling up unexpectedly.
Therapists once thought this treatment was too dangerous for people with PTSD and addiction, as digging into those images could be so traumatic that it could trigger a relapse. In 2012, researchers confronted that assumption with a study, and they found that exposure therapy didn’t make addictions worse. Even when facing their worst fears, people weren’t tempted to lean on a chemical solution.
Doctors worry about relapse because it is so prevalent in people with PTSD and addiction. Researchers say people with these two issues have stronger cravings and a quicker relapse profile than people with addiction alone.
But the more we know about effective treatments, the more we can help people to achieve real recovery from these intertwined issues.
Another type of treatment, cognitive behavioral therapy, shows promise in helping PTSD complicated by addiction. People work with therapists to:
- Understand what happened during the traumatic event and how they think about it.
- Unpack the connection between trauma, stress, and substance abuse.
- Alter the way they think about the event.
- Cope with their triggers through helpful behaviors that don’t involve substance abuse.
This is an interactive, conversational form of therapy. Doctors and clients work as a team to dig into the source of the problem so that it’s easier to change behavior and move forward.
For some people, these treatment programs happen on an outpatient basis. They live at home, and they see their doctors in appointments. Others move into treatment facilities so they can get care in a safe, sober environment.
Additional Solutions Are Available
Therapy is a core part of recovery from PTSD and addiction. But it’s not the only treatment people need to get better. Teams augment the work done in therapy with adjunct treatments to ease distress and enhance coping.
For people with PTSD, stress is a real and present problem. Intrusive memories and unwanted thoughts appear due to triggers they may not be able to avoid. When they hit, those memories can cause a racing heart, sweating, and a sense of suffocation. Calming the body’s fight-or-flight response is key to keeping a relapse away.
Alternative medicine offers multiple solutions that people can use anywhere, such as:
- Meditation. Simple, calming mantras can help to ease an overactive mind, and when they’re combined with a breathing exercise, they can soothe a distressed body too.
- Exercise. Connecting a racing heart to an active body could help to block panic attacks. Some find solace in running, while others use jumping jacks or pushups to move through a panic attack.
- Yoga. Poses can push muscles to the limit. Sitting with the discomfort can enhance a skill experts call distress tolerance. That can help people to move through discomfort without looking for an immediate solution.
- Aromatherapy. A quick sniff of a soothing scent can bring a person back to the present rather than remaining in the past.
These treatments can seem luxurious or even a little frivolous. But they do have their roots in ancient healing traditions, and they don’t rely on pills or chemicals. For some people, that holds immense appeal. They learn that they can be the source of their own healing.
Support groups can also be helpful for people with PTSD and addiction. As the National Alliance on Mental Illness explains, living with both conditions is isolating, and it’s hard to describe how difficult life is to someone who hasn’t experienced the problem personally. Support groups connect you with others who have lived through similar trauma, and there’s comfort in sitting with others who really understand you.
Support groups can also offer coaching and real-world solutions. In some meetings, you listen to speakers discuss how their problems developed and what they’ve done to make things better. Their techniques could be helpful for you too, and you might be inspired to hear how others have recovered from something you considered unsolvable.
How Long Does It Take?
Trauma can happen quickly, and PTSD can follow soon after. Recovery from the issue isn’t as quick, unfortunately. It can take time to unpack the coping habits you’ve been using, and your brain will also need time to heal from drug-related damage.
Even so, you may begin to feel better after just a few courses of therapy. And the more you work on your recovery outside of your therapy sessions, the faster your treatment will progress. You may not feel immediately better, but you’re likely to feel a tiny bit of improvement every day.
Your hard work will pay off in time. Stick with your treatment, and you’ll see for yourself.