***[The Road to Recovery 2008]{.underline}***

**Addiction and PTSD:**

**Combating Co-Occurring Disorders**

*[Shoot Date]{.underline}: December 12, 2007 [Air Date]{.underline}: May
7, 2008*

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> **Abstract**: According to studies, problems of substance abuse and
> mental illness are often intertwined. Among persons with Serious
> Psychological Distress (SPD), 27.2 percent used illicit drugs in 2006,
> compared to 12.3 percent of those without SPD. Alcohol was also abused
> more by persons with SPD (28.8 percent) than those without it (23.9
> percent). The elevated risk of substance abuse associated with SPD is
> particularly alarming with respect to post-traumatic stress disorder,
> or PTSD. PTSD can strike anyone who has been exposed to military
> combat situations, physical or sexual assault and abuse, a terrorist
> attack, serious accident, or natural disaster. This Webcast will
> examine PTSD's connection to substance abuse disorders and provide
> information on where persons in need can find treatment for one, or
> both, of these conditions.

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**[Panel #1 -- Understanding PTSD]{.underline}**

**[Key Questions]{.underline}:**

1.  **How prevalent is PTSD in both the veterans and the general
    population?**

2.  **What are the causes, symptoms, and four main signs of PTSD?**

3.  **How is PTSD linked to substance abuse and addiction?**

**Prevalence of PTSD in the General Population *(Source:
[www.ncptsd.va.gov](http://www.ncptsd.va.gov/))***

-   An estimated 6.8% of Americans experience PTSD at some point in
    their lives.

-   Women (9.7%) are more than twice as likely as men (3.6%) to develop
    PTSD.

-   About 3.6% of U.S. adults (5.2 million people) have PTSD in a given
    year.

-   In people who have experienced a traumatic event, about 8% of men
    and 20% of women develop PTSD after a trauma, and roughly 30% of
    these individuals develop a chronic form that continues on
    throughout their lifetime.

**Prevalence of PTSD in Veterans *(Source:
[www.ncptsd.va.gov](http://www.ncptsd.va.gov/))***

-   About 30% of the men and women who served in Vietnam experience
    PTSD.

-   An additional 20% to 25% have had partial PTSD at some point in
    their lives.

-   Estimates of PTSD from the Gulf War are as high as 10%.

-   Estimates from the war in Afghanistan are between 6 and 11%.

-   Current estimates of PTSD in military personnel who served in Iraq
    range from 12% to 20%.

**Causes of PTSD *(Source:
[www.ncptsd.va.gov](http://www.ncptsd.va.gov/))***

-   The traumatic events most often associated with PTSD are:

    -   combat exposure

    -   physical attack

    -   being threatened with a weapon

    -   rape

    -   sexual molestation

    -   childhood neglect

    -   childhood physical abuse

**Symptoms of PTSD *(Source:
[www.nimh.nih.gov](http://www.nimh.nih.gov/))***

-   [People often experience strong and unpleasant emotional and
    physical responses to
    disasters](http://www.nimh.nih.gov/health/topics/coping-with-traumatic-events/index.shtml).
    Reactions may include combinations of:

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-   Hopelessness

-   Helplessness

-   [depression](http://www.nimh.nih.gov/health/topics/depression/index.shtml)

-   Sleeplessness

-   [anxiousness](http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml)

-   physical pain

-   confusion

-   fear

-   anger

-   grief

-   shock

-   guilt

-   mistrust of others

-   Loss of confidence in self or others.

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-   If these reactions last for more than a month, then a person may
    have
    [PTSD](http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml).

-   People with PTSD may repeatedly re-experience a traumatic event
    through flashback episodes, nightmares, or frightening and intrusive
    thoughts, especially when something reminds them of the trauma.

**Four Main Signs of PTSD *(Source:
[www.helpguide.org](http://www.helpguide.org/))***

1.  [Re-experiencing the trauma]{.underline}: flashbacks, nightmares,
    intrusive memories and exaggerated emotional and physical reactions
    to triggers that remind the person of the trauma.

2.  [Emotional numbing]{.underline}: feeling detached, lack of emotions
    (especially positive ones), loss of interest in activities.

3.  [Avoidance]{.underline}: avoiding activities, people, or places that
    remind the person of the trauma.

4.  [Increased arousal]{.underline}: difficulty sleeping and
    concentrating, irritability, hypervigilance (being on guard), and
    exaggerated startle response.

**PTSD and Addiction *(Source: The Navy Times -- Feb 20, 2007)***

-   52 percent of people diagnosed with lifetime PTSD have also been
    diagnosed with alcohol abuse or dependence (twice as much as the
    adult population).

-   35 percent have been diagnosed with drug abuse or dependence (nearly
    three times as much as the adult population)

-   These abuse tendencies surface quickly after the events that cause
    the PTSD.

-   People suffering from PTSD tend to self-medicate, which backs up the
    claim that PTSD needs to be treated immediately.

-   An alarming 60-80 percent of Vietnam veterans who seek PTSD
    treatment have alcohol disorders, and experts who work with Iraq
    veterans are already reporting a high incidence of substance abuse
    among their clients.
    *([www.hazelden.org](http://www.hazelden.org/))*

**[Panel #2 -- Consequences and Treatments]{.underline}**

**[Key Questions]{.underline}:**

4.  **What are some long-term consequences of PTSD?**

5.  **What is Complex PTSD?**

6.  **What types of treatments are available for PTSD?**

**Long-Term Consequences of PTSD *(Source:
[www.helpguide.org](http://www.helpguide.org/))***

[1. Physiological Outcomes]{.underline}

-   neurobiological changes (alterations in brainwave activity, in size
    of brain structures, and in functioning of processes such as memory
    and fear response)

-   Psycho-physiological changes (hyper-arousal of the sympathetic
    nervous system, increased startle, sleep disturbances, increased
    neurohormonal changes that result in heightened stress and increased
    depression)

-   physical complaints that are often treated symptomatically, rather
    than as indications of PTSD (headaches, stomach or digestive
    problems, immune system problems, asthma or breathing problems,
    dizziness, chest pain, chronic pain or fibromyalgia)

[2. Psychological Outcomes]{.underline}

-   depression (major depressive episodes, or pervasive depression)

-   other anxiety disorders (such as phobias, panic, and social anxiety)

-   conduct disorders

-   dissociation (\"splitting off\" from the present, and into parts of
    the self)

-   eating disorders

[3. Social Outcomes]{.underline}

-   interpersonal problems

-   low self esteem

-   alcohol and substance use

-   employment problems

-   homelessness

-   trouble with the law

[4. Self-Destructive Behaviors]{.underline}

-   substance abuse

-   suicidal attempts

-   risky sexual behaviors leading to unplanned pregnancy or STDs,
    including HIV

-   reckless driving

-   self-injury

**Complex PTSD *(Source:
[www.helpguide.org](http://www.helpguide.org/))***

-   Caused by prolonged, extreme traumatic circumstances such as
    childhood sexual abuse, prisoner of war camps, or long-term domestic
    violence

-   Borderline Personality Disorder is also highly indicative of a
    history of trauma, and is increasingly viewed as a type of Complex
    PTSD.

-   Possible Symptoms of Complex PTSD include:

    -   severe behavioral difficulties (substance abuse, aggression,
        eating disorders)

    -   difficulty in controlling intense emotions (anger, panic, or
        depression)

    -   other mental difficulties (amnesia, dissociation, or
        Dissociative Identity Disorder---formerly known as Multiple
        Personality Disorder---which is characterized by \"splitting
        off\" parts of oneself)

**Treatment Options for PTSD *(Source:
[www.helpguide.org](http://www.helpguide.org/))***

[Psychotherapy]{.underline}

-   Because PTSD has so strongly affected the brain itself, treatment
    often takes longer and progresses more slowly than with other types
    of anxiety disorders, and is most effective with a specialist in
    trauma recovery.

-   It is most important to feel comfortable and safe with the
    therapist, so there is no additional fear or anxiety about the
    treatment itself.

-   Depending on the extent of the symptoms, it may be more effective to
    see the therapist several times a week, if possible.

-   Psychotherapy may take place in a group setting.

[Cognitive-Behavioral Therapy]{.underline}

-   Cognitive-Behavioral Therapy (CBT), often including exploring
    personal history as well as history of the event, challenging
    beliefs and thoughts that lead to distress, learning to recognize
    and manage \"triggering\" episodes, and exposure or desensitization
    (gradual re-introduction to the event that caused the trauma)

[Relaxation Techniques]{.underline}

-   Psychotherapy may include relaxation techniques (deep breathing,
    muscle relaxation, positive imagery, meditation, neurofeedback,
    prayer, etc.)

-   However, there are documented instances where relaxation was
    counterproductive---triggering rather than relieving symptoms.

[Medications]{.underline}

-   Anti-anxiety medications or anti-depressants to calm anxiety and
    stabilize mood while other self-care tools are learned.

-   Medications are used most frequently in conjunction with standard
    psychotherapies.

[EMDR Therapy]{.underline}

-   Combines a somatic therapeutic approach with eye movements or other
    forms of rhythmical stimulation, such as hand taps or sounds that
    stimulate and integrate the left and right hemispheres of the brain.

[Somatic experiencing]{.underline}

-   **I**ncorporates observations of how animals treat themselves
    following traumatic events and focuses on restoring normality to the
    stress response.

-   The symptoms of trauma result from highly activated incomplete
    biological response to threat. Wild animals have the ability to
    "shake off" this excess energy. By enabling humans to do the same,
    trauma can be healed.

**[Panel #3 -- PTSD, Mental Health, and Substance Abuse]{.underline}**

**[Key Questions]{.underline}:**

7.  **Why might PTSD sufferers be prone to substance abuse?**

8.  **Are veterans at special risk for co-occurring disorders?**

9.  **How should treatment be delivered to someone with co-occurring?**

**Substance Abuse and Mental Health Statistics *(Source: 2007 NSDUH)***

-   In 2006, among persons aged 12 or older, an estimated 22.6 million
    (9.2 percent) were classified with substance dependence or abuse in
    the past year.

-   In 2006, 4.0 million persons (1.6 percent of the population) aged 12
    or older received some kind of treatment for a problem related to
    the use of alcohol or illicit drugs.

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-   In 2006, 28.3 million adults (12.9 percent of the population 18
    years or older) received treatment for mental health problems during
    the past 12 months.

**Serious Psychological Distress, or "SPD" *(Source: 2007 NSDUH)***

-   In 2006, among adults aged 18 or older in the United States, there
    were an estimated 24.9 million adults (11.3 percent) with SPD in the
    past year.

-   10.9 million of those (44.0 percent) received treatment for a mental
    health problem in the past year. Of these:

    -   39.0 percent received a prescription medication

    -   27.2 percent received outpatient treatment

    -   3.9 percent received inpatient treatment for a mental health
        problem in the past year.

> *\[[Note]{.underline}: Respondents could report more than one type of
> treatment.\]*

**Major Depressive Episode, or "MDE" *(Source: 2007 NSDUH)***

-   In 2006, 15.8 million adults (7.2 percent of persons aged 18 or
    older) had at least one MDE in the past year.

-   In 2006, an estimated 30.4 million adults had at least one MDE in
    their lifetime (13.9 percent of persons aged 18 or older).

-   Among adults aged 18 or older who had MDE in 2006, 24.3 percent were
    dependent on or abused alcohol or illicit drugs, while among adults
    without MDE only 8.1 percent were dependent on or abused alcohol or
    illicit drugs.

**Co-Occurring Disorders *(Source: 2007 NSDUH)***

-   Among the 5.6 million adults aged 18 or older with both SPD and a
    substance use disorder in 2006, 50.8 percent received some sort of
    treatment:

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-   39.6 percent received treatment only for mental health problems.

-   2.8 percent received specialty treatment only for substance use.

-   8.4 percent received simultaneous treatment for mental health
    problems and specialty substance use.

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-   Among youths with a major depressive episode in the past year:

    -   23.9 percent saw or talked to a medical doctor or other
        professional only

    -   2.1 percent used prescription medication only

    -   12.7 percent received treatment from both sources.

**Importance of Treating Co-Occurring Disorders Simultaneously *(Source:
TASC)***

-   Ensuring that treatment is available and accessible for both
    disorders is essential to providing a successful path of recovery.

-   Many types of co-occurring mental health problems can be
    successfully addressed in standard drug abuse treatment programs.

-   Although not readily available, specialized therapeutic community
    "MICA" (for "mentally ill chemical abuser") programs are promising
    for patients with co-occurring mental and addictive problems.

**Treating Co-Occurring Disorders with Medication *(Source: TASC)***

-   Much progress has been made in developing effective medications for
    treating mental disorders, including a number of antidepressants,
    mood stabilizers, and antipsychotics.

-   Contingency management can improve adherence to prescribed
    medications, and intensive case management may be useful for linking
    severely mentally ill individuals with drug abuse treatment, mental
    health care, and community services.

-   Cognitive-behavioral therapy can be effective for treating mental
    health problems, particularly when combined with medications.

**Psychotherapeutics, i.e. "Prescription Drug Abuse" *(Source: 2007
NSDUH)***

-   Psychotherapeutics include the nonmedical use of any
    prescription-type pain relievers, tranquilizers, stimulants, or
    sedatives. Over-the-counter substances are not included.

-   The number of persons aged 12 or older who used psychotherapeutics
    nonmedically for the first time within the past year rose from
    647,000 in 2005 to 2.6 million in 2006.

-   Among persons aged 12 or older who used pain relievers nonmedically
    in the past 12 months, 55.7 percent reported that they got the pain
    relievers they most recently used from a friend or relative for
    free.

**Personalizing Treatment**

-   No single treatment is appropriate for all individuals. Types of
    treatment greatly depend on the substances misused, as well as a
    person's individual needs and characteristics.

-   Effective treatment attends to multiple needs of the individual, not
    just his or her drug addiction.

-   An individual's treatment and services plan must be assessed often
    and modified to meet the person's changing needs.

-   It is essential that people with substance use disorders and their
    providers identify the most appropriate course of treatment to meet
    their specific needs. Just as substance use disorders can affect
    people regardless of their age, race, ethnicity, class, employment
    status, or community, treatment services also should respect these
    unique characteristics.

**[Panel #4 -- Attacking PTSD]{.underline}**

**[Key Questions]{.underline}:**

10. **Why might people react differently to the same traumatic event?**

11. **What should relief workers do -- and *not* do -- when helping
    someone through a traumatic event?**

12. **What could prevent someone from gaining access to treatment?**

**Reasons for Varying Reactions to a Traumatic Event *(Source:
[www.helpguide.org](http://www.helpguide.org/))***

-   The extent to which the event was unexpected, uncontrollable, and
    inescapable

-   Perceived extent of threat or danger, suffering, upset, terror, and
    fear

-   Source of the trauma (human-caused is generally more difficult than
    event of nature)

-   Sexual victimization, especially when a sense of betrayal is
    involved

-   Actual or perceived responsibility

-   Prior vulnerability factors (genetics, early onset and extent of
    childhood trauma)

-   Negative social environment (shame, guilt, stigmatization)

-   Lack of appropriate social or emotional support

-   Concurrent stressful life events

**Tips for Relief Workers *(Source:
[www.nimh.nih.gov](http://www.nimh.nih.gov/))***

-   Create and sustain an environment of safety, calm, connectedness to
    others, self-empowerment, and hopefulness.

-   Help people meet basic needs for food and shelter, and obtain
    emergency medical attention

-   Provide repeated, simple, and accurate information on how to obtain
    these services

-   Listen to people who wish to share their stories and emotions and
    withhold judgment

-   Be friendly and compassionate even if people are being difficult

-   Provide accurate information about the disaster and the relief
    efforts

-   Help people contact friends or loved-ones

-   Keep families together; keep children with parents or other close
    relatives whenever possible

-   Give practical suggestions that steer people toward helping
    themselves

-   If you know that more help and services are on the way, remind
    people of this when they express fear or worry

**Things for Relief Workers to Avoid *(Source:
[www.nimh.nih.gov](http://www.nimh.nih.gov/))***

-   Forcing people to share their stories with you, especially very
    personal details (this may decrease calm in people who are not ready
    to share their experiences)

-   Telling people what you think they should be feeling, thinking, or
    doing now or how they should have acted earlier

-   Making promises that may not be kept (broken promises decrease hope)

-   Criticizing existing services or relief activities in front of
    people in need of these services (this may decrease hope or calm)

**Barriers to Treatment for PTSD *(Source:
[www.helpguide.org](http://www.helpguide.org/))***

-   Symptoms may occur months or years after the traumatic event and may
    not be recognized as being related to the trauma.

-   Beliefs that people \"should be able to get over it\" or
    \"shouldn\'t have such a reaction\" or \"should solve their own
    problems\" may delay treatment being sought.

-   Guilt, blame, embarrassment or pain may interfere with a person
    seeking help.

-   Avoidance of anything associated with the trauma may result in an
    inability to recognize the need for treatment.

**Stigma**

-   An estimated 22 to 23 percent of the U.S. population experiences a
    mental disorder in any given year, but almost half of these
    individuals do not seek treatment. *(U.S. Department of Health and
    Human Services \[HHS\])*

-   Embarrassment and shame often are listed as the second most common
    barriers to recovery.[^1]

-   Stigma is a barrier. Fear of stigma, and the resulting
    discrimination, discourages individuals and their families from
    getting the help they need.

**Recovery Month**

-   The *Recovery Month* effort aims to promote the societal benefits of
    alcohol and drug use disorder treatment, laud the contributions of
    treatment providers and promote the message that recovery from
    alcohol and drug use disorders in all its forms is possible.

13. **Where can one find more information on PTSD and addiction?**

[PTSD Resources]{.underline}

-   **U.S. Department of Veterans Affairs, National Center for PTSD**

> [www.ncptsd.va.gov](http://www.ncptsd.va.gov/)

-   **Iraq War Veterans Organization, Inc.**

[www.iraqwarveterans.org](http://www.iraqwarveterans.org/)

-   **Hazelden**

> [www.hazelden.org](http://www.hazelden.org/)

-   **National Treatment Accountability for Safer Communities (TASC)**

> [www.nationaltasc.org](http://www.nationaltasc.org/)

-   **PTSD Support Services**

> [www.ptsdsupport.net](http://www.ptsdsupport.net/)

-   **Military Veterans PTSD Manual**

> [www.ptsdmanual.com](http://www.ptsdmanual.com/)

-   **PTSD Forum**

> [www.ptsdforum.org](http://www.ptsdforum.org/)

**[Additional Resources]{.underline}**

-   **The Substance Abuse and Mental Health Services Administration
    (SAMHSA)**

[www.samhsa.gov](http://www.samhsa.gov/)

-   **The Center for Substance Abuse Prevention (CSAP)**

[prevention.samhsa.gov](http://www.prevention.samhsa.gov/)

-   **The Center for Substance Abuse Treatment (CSAT)**

[csat.samhsa.gov](http://www.csat.samhsa.gov/)

-   **National Institute on Alcohol Abuse and Alcoholism (NIAAA)**

[www.niaaa.nih.gov](http://www.niaaa.nih.gov/)

-   **National Institute on Drug Abuse**

> [www.nida.nih.gov](http://www.nida.nih.gov/)

-   **National Institute of Mental Health**

[www.nimh.nih.gov](http://www.nimh.nih.gov/)

-   **National Association for Children of Alcoholics (NACoA)**

[www.nacoa.org](http://www.nacoa.org/)

-   **Alcoholics Anonymous (AA)**

[www.alcoholics-anonymous.org](http://www.alcoholics-anonymous.org/)

-   **Narcotics Anonymous (NA)**

[www.na.org](http://www.na.org/)

-   **Al-anon/Alateen**

[www.al-anon.alateen.org](http://www.al-anon.alateen.org/)

-   **Faces and Voices of Recovery**

[www.facesandvoicesofrecovery.org](http://www.facesandvoicesofrecovery.org/)

[^1]: Peter D. Hart Research Associates, Inc. October 2001. *The Face of
    Recovery.* Washington, DC: Peter D. Hart Research Associates, Inc.,
    p. 10.