WHO Analysis Expands on Trauma, PTSD Association (Source, Liu H, et al. JAMA Psychiatry, 04.01.2017)
Previous traumatic experiences were generally associated with PTSD. This is the analysis result of a large cross-national community sample which indicated that generalized risk was limited to previous exposure to violence and sexual assault.
Howard Liu of Harvard Medical School stated that PTSD prevalence is highest for (traumatic experiences) involving interpersonal violence. He further stressed that some research suggests that traumatic experience is a risk factor for subsequent PTSD, with prior (traumatic experience) involving violence. On the other hand, these studies did not examine prior (traumatic experience) comprehensively. This makes it unclear whether the special importance of (traumatic experience) involving interpersonal violence is limited to personal experience of this violence or includes witnessing extreme violence. Furthermore, it is also a question whether repeated exposure to similar (traumatic experience) is of special importance.
Researchers administered WHO World Mental Health surveys that assessed 29 types of traumatic experiences and DSM-IV PTSD in 20 countries from 2001 to 2012 to determine associations of type of traumatic experience history with PTSD.
Risk for PTSD was higher among participants with traumatic experiences involving sexual violence (OR = 2.7; 95% CI, 2-3.8) and witnessing atrocities (OR = 4.2; 95% CI, 1-17.8).
Prior lifetime group-level, same-type traumatic experiences was significantly associated with PTSD (P = .01).
Prior exposure to physical violence in the presence of a prior same-type traumatic experience (OR = 3.2; 95% CI, 1.3-7.9) was associated with increased risk for PTSD, while participation in organized violence in the presence of a prior same-type traumatic experience (OR = 0.2; 95% CI, 0.1-0.8) was associated with decreased risk.
Current findings replicated previous findings that associated increased risk for PTSD with a general history of traumatic experiences, however; generalized risk was limited to prior traumatic experiences involving violence, including participation in organized violence (OR = 1.3; 95% CI, 1-1.6), physical violence (OR = 1.4; 95% CI, 1.2-1.7), rape (OR = 2.5; 95% CI, 1.7-3.8) and other sexual assault (OR = 1.6; 95% CI, 1.1-2.3).
Researchers concluded that results are valuable in advancing understanding of complex ways in which specific traumatic experiences and histories are associated with PTSD. There are questions unresolved about casual pathways and mechanisms but this contributes in providing a foundation for more focused investigations.
Post Traumatic Stress Disorder (PTSD) and Addiction:
“Physically or emotionally traumatized people are at much higher risk of abusing licit, illicit, and prescription drugs,” reports the National Institute of Drug Abuse (Exposure, n.d., para. 2). According to current epidemiological studies in the United States, it appears that as many as half of all veterans who have PTSD have a co-occurring SUD (Ibid., n.d.). SUD stands for Substance Use Disorder, which can be used as a non-stigmatizing, neutral term for addiction to either alcohol or drugs. Female SUD patients in clinical samples were found to have PTSD rates which ranged from 25% -55% (Miele, 2004). Najavits (2009) described the US population lifetime rates of co-occurring SUD and PTSD from men and women. Fifty-two percent of the men with PTSD had alcohol use disorder and 35% had drug use disorder. Twenty-eight percent of the women with PTSD had alcohol use disorder and 17% had drug use disorder. Cook (n.d.) reported that the odds of drug use are three times higher in individuals with PTSD, and when PTSD or SUD present alone, there is an increased risk of developing the other. In general, it can be said that substance use disorders, predominantly abuse of and dependence on central nervous system (CNS) depressants, is a common phenomenon among individuals with PTSD (Jacobsen, Southwick & Kosten, 2001). There are a number of theories and studies that explain the relationship between PTSD and substance use/abuse.
1. High-Risk Theory:
According to high risk theory individuals who use drugs and alcohol put themselves at high risk for experiencing traumatic events and because of this will have higher rates of PTSD (Tull, 2010). In a study of 440 not-in-treatment crack-cocaine users, for example, findings indicated that physical attack was widespread. Gender differences were also apparent, as men showed lower rates of attacks compared to women. Injuries sustained during the attacks frequently were serious enough to require for medical care (Siegal, Falck, Wang & Carson, 2000). There are known correlations between excessive use of alcohol and drugs and victimization. Hook, Murray and Seymore (2005) described scenarios in which individuals under the influence of drugs and alcohol become victims of crimes:
People under the influence
• Have poor judgment and might put themselves into risky situations with dangerous people.
• Become more vulnerable to crime because they may be less aware of what is going on and are not able to protect, or remove themselves from a dangerous situation.
• Are more vulnerable because they can fall prey to predators who seek to take advantage of high individuals.
• Might remain passive due to the dulling effects of drugs and alcohol.
• Might spend time in environments where substance abuse is common and might attract criminal behavior (e.g. binge drinking and sexual assaults on college campuses).
• Spend time in environments where purchasing illegal drugs is condoned and that might attract other criminal behavior.
It is evident that alcohol and drug consumption carries a host of possible problems that put users at greater risk for physical and emotional harm that may cause PTSD.
2. Self-Medication Theory:
This theory states that drug and alcohol are used as a means of reducing distress relating to PTSD symptoms (Tull, 2010). Volpicelli, Balaraman, Hahn, Wallace and Bux, 1999) reported that victims of sexual or physical traumas turn to alcohol to relieve symptoms of anxiety, irritability, and depression. Specifically, they spoke of traumas that were experienced as uncontrollable and thus brought up feelings of terror and helplessness. To understand the role of alcohol biochemical changes that occur during and after an uncontrollable trauma must be understood. During a traumatic episode, the brain releases endogenous opioids which are endorphins that help numb the pain of the event. After the trauma, a rebound endorphin withdrawal can add to the symptoms of emotional distress and increase the desire to drink. Hence, drinking behavior is explained as a person’s attempt to relieve the endorphin deficiency. This concept has been named the “endorphin compensation hypothesis.” Based on this hypothesis drinking alcohol initiates a vicious cycle where more alcohol is needed to avoid later endorphin withdrawal symptoms. If this addictive cycle continues over a period of time dependency can occur.
Ruzek, Polusny and Abueg (n.d.) described the self-medication hypothesis in the following way: They spoke of substance abuse as a form of emotional avoidance which has was defined as, “’the unwillingness to experience unpleasant internal events, such as thoughts, memories, and affective states associated with an abuse history, and subsequent attempts to reduce, numb, or alleviate these negatively self-evaluated internal experiences’” (p. 228). Additionally, they proposed that the consumption of alcohol and drugs may be maintained based on the perception of positive aspects of use. Examples for this are feeling a sense of control, increasing social confidence, gaining access to social contacts and, most importantly, enhancement of positive affect or other desirable emotional experiences. The acute effects of alcohol or drugs might provide an avenue for individuals to express sadness and rage. It has also been found that individuals suffering from PTSD who have significant avoidance/numbing symptoms might seek sensations that under sober circumstances would be dulled.
3. Susceptibility Theory/Shared Vulnerability Theory
The susceptibility theory suggests that there is something about alcohol and drug use that may increase a person’s risk for developing PTSD symptoms after experiencing a traumatic event. The idea behind this theory is that drug and alcohol consumption changes the brain in ways that puts individuals at higher risk of developing PTSD after a traumatic experience. As far as shared vulnerability is concerned, the focus lies on individuals’ genetic vulnerability that increases the chances of developing both PTSD and substance abuse problems after a traumatic event (Tull, 2000). In sum, neurophysiologic systems and genetics are investigated and implicated in the co-morbidity of PTSD and SUD.
Ries, Miller, Fiellin, and Saiz (2009) reported on the validity of all three theories in the etiologic relationship between PTSD and SUD. They maintained that the most prominent one is the Self-Medication Theory, followed by High Risk Theory and Susceptibility Theory. These researchers felt that the causal relationship between co-morbid PTSD and SUD most likely varies from individual to individual and that continued research is indicated to further illuminate this topic.
List of References:
Cook, J.W. (n.d.). PTSD and substance use disorders. William S. Middleton Memorial VA University of Wisconsin School of Medicine and Public Health. Retrieved October 22, 2011, from http://www.wisspd.org/htm/ATPracGuides/Training/ProgMaterials/Vet/PandA.pdf
Exposure to traumatic events puts people at higher risk of substance use disorders (n.d.). NIDA: National Institute on Drug Abuse, Research Report Series: Comorbidity: Addiction and Other Mental Illnesses. Retrieved October 18, 2011, from http://www.drugabuse.gov/ResearchReports/comorbidity/diagnosed.html
Hook, M., Murray, M. & Seymour, A. (2005). Substance abuse and victimization video discussion guide. U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime. Retrieved, October 23, 2011, from http://www.ojp.usdoj.gov/ovc/pdftxt/substance_abuse_victimization_vdguide.pdf
Jacobson, L. K., Southwick, S.M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. Review and Overviews. Retrieved October 21, 2011, from http://188.8.131.52/boundary/Childhood_trauma_and_PTSD/ptsd_and_addiction.pdf
Miele, G. M. (2004). PTSD and substance use: Women and co-morbidity workshop, NY State Psychiatric Institute/Columbia University. Retrieved October 21, 2011, from http://www.seiservices.com/archive/blendingdetroit/presentation/miele%20workshop9.pdf
Najavits, L.M. (2009). PTSD and substance abuse. A web course within PTSD: 101, An Educational Resource for Health Professionals. Retrieved October 26, 2011, from http://www.ptsd.va.gov/professional/ptsd101/flash-files/Substance_Abuse/player.html
Ruzek, J.I., Polusny, M.A. & Abueg, F.R. (n.d.). Assessment and treatment of concurrent posttraumatic stress disorder and substance abuse. Retrieved October 23, 2011, from http://mirecc.stanford.edu/pdf/ptsd/Concurrent%20PTSD_SA.pdf
Siegal, H.A., Falck, R.S., Wang, J. & Carson, R. (2000). Crack-cocaine users as victims of physical attack (n.d.). NIDA: National Institute on Drug Abuse: Women and Sex/Gender differences Research. Retrieved October 22, 2011, from http://www.drugabuse.gov/WHGD/WHGDDirRep17.html
Tull, M. (2010). The connection between PTSD and alcohol and drug use. Parentsonline. Retrieved October 22, from http://www.bamaol.cc/PsychologicalTopic/PTSD/4946.html
Volpicelli, J, Balaraman, G., Hahn, J., Wallace, H. & Bux, D. (1999). The role of uncontrollable trauma in the development of PTSD and alcohol addiction. Alcohol Research & Health. 23(4). Retrieved October 23, 2011, from http://pubs.niaaa.nih.gov/publications/arh23-4/256-262.pdf