Trauma and Addiction: Common Origins and Integrated Treatment

As much as anything can be known, we know there is a strong connection between trauma and addiction. Of a sample of over 10,000 men and women, 34% of those with PTSD had one or more substance use disorders (SUDs). About two-thirds of people with substance use disorders have experienced trauma in their pasts, and about half meet the criteria for PTSD.

Scientists have investigated the trauma-addiction connection and, while causality cannot be proven, current evidence indicates that trauma causes addiction rather than the reverse. Maia Szalavitz, in her book Unbroken Brain, reports that, “Even just one extreme adversity – like losing a parent or witnessing domestic violence – before age 15 doubles the odds of substance use disorders, according to a study of the entire Swedish population” (Unbroken Brain, 65). Consistent with the self-medication hypothesis, the theory that people use substances to cope with psychological distress, PTSD tends to precede and predict SUD.

Furthermore, scientists have discovered common biological mechanisms for the development and persistence of both PTSD and SUD. For example, both disorders involve dysfunction with the same neurotransmitters (though researchers don’t yet understand how they are specifically involved in the development of comorbid PTSD and SUD).

“Dopamine, norepinephrine, and serotonin have been independently implicated in mechanisms associated with PTSD and A/SUD such as reward, impulsivity, arousal, and anxiety.” – Norman et al., 2012

Norman et al. also reports that the neuroendocrine system, responsible for processing stress, is affected by both PTSD and SUD. Corticotropin-releasing hormone (CRH) is secreted under stressful conditions, and is found in higher concentrations in patients with PTSD. It is associated with higher drug intake in rat studies, as well as stronger cravings in human studies. CRH  is also known to worsen withdrawal symptoms.

“In other words, individuals with PTSD may experience elevated CRH in the brain which may increase the euphoric feelings caused by many drugs and/or worsen withdrawal symptoms. Additionally, CRH elevations seen during withdrawal may increase hyperarousal symptoms, which in turn may increase other PTSD symptoms triggering relapse (i.e., self-medication).” – Norman et al., 2012

Given the strong statistical and biological connection between PTSD and SUD, it makes good sense to study treatments that address both disorders at once. Meta-studies examining treatment efficacy for comorbid SUD and PTSD have documented that trauma-focused treatments reduce symptoms for both disorders more effectively than SUD treatments alone (Norman et al., 2012; Berenz and Coffey, 2013). Pioneering researchers, including Jennifer Mitchell, are exploring the possibility that oxytocin, the hormone that allows people and other mammals to form social bonds, may lessen the stress response and treat both PTSD and addiction.

Pharmaceutical and behavioral therapy treatments for PTSD abound, but certain treatments have more scientific support.

• Eye Movement Desensitization and Reprocessing (EMDR)
  (Schubert, Lee, and Drummond, 2016; Novo Navarro et al., 2016; Acarturk et al., 2016; Smith, 2015; Chen et al., 2014; Jeffries and Davis, 2013; Leer, Engelhard, and van den Hout, 2014),
• Cognitive Processing Therapy (CPT)
  (Morland et al., 2014; Lloyd et al., 2014; Forbes et al., 2012; Resick et al., 2008; Monson et al., 2006),
• and Prolonged Exposure Therapy (PE)
  (Resick et al., 2012; van Minnen et al., 2012; Killeen, Back, and Brady, 2011; Powers et al., 2010; Schnurr et al., 2007; Rothbaum, Astin, and Marsteller, 2005; van Minnen, Arntz, and Keijsers, 2002)

are all effective therapy treatments for PTSD, supported by randomized controlled trials and meta-studies of the PTSD treatment literature (Haagen et al., 2015; Gerger et al., 2014; Ehring et al., 2014; Watts et al., 2013). A meta-study of pharmacological interventions for PTSD found that serotonin selective reuptake inhibitors (SSRIs) are most effective for treating symptoms of PTSD, such as depression.

PTSD and SUD therapists alike have been suspicious of exposure-based treatments for years. For example, well-known trauma therapist Babette Rothschild shares case studies of patients she has treated who were retraumatized by exposure therapy. Rothschild also writes in her book, Trauma Essentials: The Go-To Guide, that there have been both documented and unofficial reports of high dropout rates from prolonged exposure treatments, citing Kubetin, 2003. This article by Kubetin, published in Clinical Psychiatry News magazine, quotes Dr. Richard Bryant reporting that 20% of patients (sample size of 40) find prolonged exposure therapy too intense to continue and another 20% do not respond to the therapy within 6 months.

However, the position that exposure-based therapies are retraumatizing is not supported by the literature. A meta-study examining the potential contraindications of PE found that while PE is not advised for patients who are actively suicidal, the treatment is safe for patients with other comorbidities, including substance use disorders. Another meta-analysis, examining dropout from trauma treatments, found no difference in dropout rates due to the degree of clinical attention placed on the traumatic event.

Prolonged Exposure Therapy has been shown to be effective in treating PTSD with many different origins, as well as comorbid PTSD and SUD (McCauley et al., 2012; van Minnen et al., 2012). Randomized controlled trials of PE for comorbid PTSD and SUD have demonstrated greater benefits for patients receiving PE than those receiving cognitive behavioral therapy or usual treatment for SUDs (Sannibale et al., 2013; Mills et al., 2012).

Still, just as a single case cannot be stretched to apply to all cases, statistics do not invalidate an individual’s experience. If a patient is experiencing worse symptoms after beginning exposure therapy, the treatment should be stopped. People may feel worse at first in exposure therapy, and often in other psychological therapies too, as they address the problems they have been having. But if they continue to feel distressed after a period of time decided upon by both patient and provider, other treatments need to be explored.

The significant relationship between trauma and addiction, and the success researchers have seen in integrating trauma and addiction treatments is well-established. Evidence-based trauma treatments, such as PE, EMDR, and CPT, should be a first-line approach for the 50+% of SUD patients with comorbid PTSD.

In fact, if trauma is a causal factor in the development of addiction, trauma treatment may be one of the most important preventative measures to invest in to reduce addiction rates across the country.

Image by No Lotus Design, used with permission.

This post was last updated 5/4/17.