The Trauma-Addiction Interaction
By Dr. Sara Aharon, psychologist
The impact of psychological trauma on mental health has been under-estimated. Clinical experience and a growing body of research is linking trauma to chronic depression, bi-polar disorder, anxiety disorders, dissociation, anger and rage, attachment disorders, personality disorders and even psychosis. This suggests it is time to expand our understanding of the impact of trauma beyond Post Traumatic Stress Disorder (PTSD). A medical model of mental health emphasizes the role of genetic vulnerability and biochemical imbalances in these disorders and tends to treat them with psychopharmacological medications such as SSRIs, anti-psychotic and anti-anxiety medications. However, unresolved trauma can be a cause for any of these disorders or may contribute to their development and maintenance in combination with genetic vulnerability and other factors.
According to John Briere, a trauma expert, it is very rare to find people who develop only PTSD following a traumatic event. An American National Co morbidity Survey found that 80% of all of those diagnosed with PTSD had at least one other affective, anxiety or chemical use/dependency disorder (Briere, 2004). PTSD appears to be only part of the post-traumatic response.
Recognizing trauma as a causal or contributing factor in mental health requires modifying the assessment process and treatment. An integral part of the treatment needs to include addressing the unresolved aspect of the trauma, when a depressed individual, for example, reports trauma history.
What is Trauma?
There are different ways to define trauma. This writer’s favourite definition is that of Bessel van der Kolk’s (1987) an expert in the field of trauma:
“Trauma, by definition, is the result of exposure to an inescapably stressful event that overwhelms a person’s coping mechanism.”
This definition captures the interaction between the event and the person, as no two people will react to the same event in exactly the same way. Individuals’ ability to cope with any stressful or potentially traumatic event depends on many variables. For example, important factors are their belief system, the presence of previous traumatic events, chronic or highly stressful experiences, level of support they have in their lives, as well as, perception of their ability to cope with an event, internal resources such as coping strategies, genetic pre-disposition and the presence of other stressors in their lives at the time of the event.
What Makes An Event “Traumatic”?
An exposure to a “catastrophic” event or extreme stress is necessary but not sufficient to define an event as “traumatic”. The critical discriminator is the person’s emotional response to the event. An intense emotional response such as fear, helplessness, powerlessness or terror would render an event traumatic. Emotional responses are closely tied to the factors mentioned above. For example, people who survived a hurricane which damaged their house will react differently if they trust their ability to cope, have social support and sufficient financial resources and generally believe that things will eventually work out compared to those who lack support and financial means and experience life as a series of repeated and inevitable negative events.
Childhood trauma in the form of abuse, neglect or abandonment is gaining recognition among trauma specialists such as Briere and van der Kolk as a cause for severe psychological difficulties in adulthood. Briere claims that childhood neglect results in the worst psychological dysfunction. van der Kolk believes that the impact of childhood abuse and neglect is so devastating, he is proposing a new category for the next edition of the DSM (Diagnostic Manual for the Diagnosis of Mental Disorders) called Developmental Trauma Disorder (2005).
- American surveys suggest that 39% to 75% of people in the general population have experienced at least one major traumatic stressor (Briere, 2004).
- Recent studies suggest that prevalence of rape or assault by a current or previous spouse of women in the U.S. is around 22% and for men 7% (Briere. 2004).
- Over 3 million children are reported each year to be abused or neglected in the US (Wang & Daro, 1997).
- Studies show that about a third of abused or neglected children meet criteria for a diagnosis of PTSD. Examples of other diagnoses include: separation anxiety, oppositional defiance disorder, phobias, ADHD (van der Kolk in Yehuda, 2001).
- 35%-70% of mental health female patients, if asked, report childhood sexual abuse (Briere, 2004).
- Kilpatrick and Resnick (1993, in Briere, 2004) found that: 12.5% of victims studied still had PTSD 15 years after being raped.
- The psychological effects of rape are wide ranging: fear, anxiety, anger, depression, low self-esteem, sexual difficulties, suicidality, substance use disorders, dissociative symptoms and PTSD.
Certain characteristics of highly stressful events are more likely to result in long-lasting psychological disturbances. Interpersonal victimization is associated with greater psychological difficulties and symptoms. The intensity of the physiological response to the event is also associated with worse post-trauma symptoms.
A person’s ability to take action to protect oneself or even to flee the situation is another important factor in the development of post-trauma symptoms. People who are immobilized during the trauma, whether it is because they froze, or because it was not possible for them to act, report greater severity of symptoms following traumatic events. An important task for trauma survivors is to identify the ways in which they can protect themselves in the present and regain a sense of power.
How severe or how long a person will suffer from trauma-related symptoms will be affected by what happens after the trauma, in the days, weeks, months and even years to come. Social isolation, shame and guilt, not asking for or accepting help, secondary gains (financial benefits for example), focusing on the losses of past self/life, and lack of resources all play a role in the post-trauma response. Secondary wounds are often overlooked. These include lack of validation and support, blaming the victim, stigmatization, and denial of assistance are all exacerbating factors.
What is Addiction?
The physical and psychological craving for a substance or behaviour that develops into a dependency and continues even though it is causing the addicted person physical, psychological and social harm.
If you asked a group of eight year olds what they want to be when they grow up, none of them would answer “to be an addict”. So why do so many people end up caught in the painful web of a lifestyle of addiction despite the terrible consequences? Most studies exploring which came first, alcohol-use disorders or PTSD found that PTSD preceded the alcohol problem (i.e. PTSD was the primary disorder). A case in point: a review of addiction-related studies shows that approximately 50% to 60% of women and 20% of men in chemical dependency recovery programs report having been victims of childhood sexual abuse.
Addictive behaviour in the context of trauma can be seen as a form of self-medication and/or as an unhealthy coping mechanism. Survivors are typically plagued by numerous symptoms. From an inability to sleep, constant irritability and cognitive difficulties to flashbacks and dissociation to name a few, survivors are faced with ongoing challenges in coping with the activities of daily living, including work, school, social and leisure.
It may not be so surprising, therefore, that so many trauma survivors become addicts. Trauma survivors use substances because substances and addictive behaviours are the fastest, most effective ways to: numb the pain of trauma; block memories, negative feelings and thoughts; escape to a different, initially less painful reality; attain relief from symptoms through all of the above or simply to get through the day.
Trauma-related symptoms are common triggers of substance abuse. For example, heroin may be used due to its muting effects on rage and aggression, while cocaine may be adopted for its antidepressant effects. Once addicted, the person is caught in a vicious cycle whereby substance abuse exacerbates symptoms of other psychological disorders, while psychological disorders such as PTSD, anxiety and depression, increase the likelihood of substance abuse. Withdrawal symptoms from substances may exacerbate the conditions and the associated symptoms. Substance abuse also increases vulnerability to new traumatic experiences, which in turn lead to more substance abuse. Therefore, treating trauma-related disorders and addiction concurrently is essential to successfully breaking this vicious cycle.
We can no longer ignore the impact of trauma and addiction on our lives and on the lives of our friends and loved ones. Both addiction and trauma-related symptoms and disorders are treatable. Asking for and accepting help is a crucial first step.