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Dual Diagnosis Detox & PTSD

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Post traumatic stress disorder (PTSD) and substance addictions often co-occur, and it can be difficult to manage both conditions at the same time. If you’re struggling with an addiction and co-occurring PTSD, there is experienced support available to help you find the appropriate detox and treatment program.

What is Dual Diagnosis?

Getting assessed by a professional.Mental health professionals use the term dual diagnosis to identify someone who is suffering from both a diagnosed mental health disorder, such as PTSD, and a substance use disorder, or addiction.1 It is essential to identify when a person has a dual diagnosis because the treatment necessary to fully address both conditions is more complex when compared to treating one disorder alone. Furthermore, identification of dual disorders can potentially lead to better treatment outcomes.1,2

It’s important to be aware of the signs and symptoms of each disorder by itself before you can understand how they influence and affect one another. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), you might have a substance use disorder based on the following criteria:3

  • Continuing to use a substance despite physical or psychological harm associated with use
  • Using larger amounts of the substance or using it for a longer period than originally intended
  • Failing to quit or cut back on use despite desiring to
  • Failing to fulfill responsibilities at home, school, or work due to substance use
  • Neglecting previously enjoyed activities or hobbies due to substance use
  • Spending a significant amount of time trying to find, use, or recover from the substance
  • Experiencing severe cravings
  • Using regardless of interpersonal or social issues caused by use
  • Developing tolerance, which occurs when you need more of the substance to achieve the wanted effects
  • Experiencing withdrawal symptoms, which emerge when you abruptly discontinue or dramatically reduce use

Physicians, addiction professionals, and therapists use these signs and symptoms and the answers you provide to determine the severity of your substance use disorder.3 Generally speaking, severity is based on the number of symptoms present and not solely on whether you have developed a tolerance or have experienced withdrawal symptoms.3 If you find that you cannot control your substance abuse, you may be struggling with a drug or alcohol addiction.

Posttraumatic stress disorder is a mental health disorder that can develop after exposure to a deadly, violent, or injurious event through direct experience, witnessing it, learning about it happening to a loved one, or being routinely exposed to its effects.3 Some signs and symptoms of PTSD include persistent and involuntary memories, nightmares, flashbacks, or psychological and physical distress caused by things that remind you of the event.3

Additional symptoms of PTSD include:3, 4

  • Avoiding distressing feelings, thoughts, or memories associated with the event.
  • Avoiding people, places, or situations that remind you of the trauma.
  • Experiencing memory loss connected with the event’s details (not due to head trauma or substance use).
  • Feeling constant and overwhelming negative ideas about yourself, the world, or other people.
  • Experiencing distorted thoughts about the cause or ramifications of the traumatic event that cause you to blame yourself or others.
  • Experiencing feelings of fear, terror, shame, helplessness, or anger.
  • Exhibiting a lack of interest in activities that you once loved.
  • Feeling detached from others.
  • Failing to experience positive emotions, such as satisfaction, love, or happiness.
  • Experiencing impaired concentration.
  • Displaying angry or irritable behavior.
  • Engaging in self-destructive or dangerous behaviors.
  • Struggling to fall asleep or stay asleep.

If you are experiencing any of these symptoms following a traumatic event, it would be beneficial to receive professional help.

Treatment professionals will ask about the duration of PTSD signs and symptoms, specifically whether they have lasted longer than one month and cause a lot of distress and impairment.3 In order to meet the criteria for PTSD, the symptoms must not be attributable to the effects of drugs or alcohol or a medical condition.3 This can be difficult to ascertain if co-occurring disorders are present. The best way for a professional to conduct an accurate assessment in those struggling with substance abuse is to wait until a certain period of abstinence has been obtained before evaluating the PTSD symptoms.2  

Victims of emotional and physical trauma have an increased risk of developing an addiction to drugs or alcohol. Stress, anxiety, and a need to avoid the difficult feelings associated with PTSD can lead a person to turn to alcohol or other drugs to feel fewer or less intense symptoms. This way of controlling symptoms is known as self-medicating.5 Chronic drug or alcohol abuse can lead to a problematic pattern of substance abuse and ultimately, addiction.

If two disorders occur at the same time or are sequential, they are considered to be comorbid conditions.6 Substance use disorders and mental health disorders, such as PTSD, interact with each other, which can impact the course of treatment, as well as treatment outcomes.6

In 2014, nearly 8 million people had a co-occurring disorder.7 According to the National Institute on Drug Abuse (NIDA), approximately 50% of individuals with a psychiatric condition will develop a drug or alcohol addiction, or vice versa.8 Within this sample, high rates of anxiety disorders occur, including PTSD.8 The connection between an alcohol or drug addiction and PTSD is particularly concerning for veterans, with about 8% of veterans having PTSD at some point in their lives. Of the veterans diagnosed with PTSD, about 20% also have a co-occurring addiction.5

If you think that you or someone you know is struggling with a dual diagnosis, it’s important to undergo a thorough assessment so that an appropriate detox and treatment plan can be created.

Importance of Evaluations

When a person presents at a mental health facility, a counselor may provide an assessment for a substance use disorder as well. Likewise, a person who visits an addiction treatment facility is likely to be screened for a mental health disorder.1 Questions will be asked about a person’s substance abuse history and how substance use may have interacted with their mental wellness. Assessments evaluate issues related to work, social activities, personal goals, and housing. Physical and laboratory examinations will be conducted to reveal for any pertinent physical health issues, such as viral infection. A mental health history and mental status examination will inquire about any desire for self-harm or harm to others.1

Substance abuse treatment consultation.Given that PTSD and substance use disorders frequently co-occur, a mental health professional may use several screening tools that assess for trauma and PTSD, and another set of tools that screen and assess for substance abuse. Biological assessments are also likely (e.g., those that test urine, hair samples, and saliva for biological information and toxicology screening). Once a diagnosis is made, the person’s symptom severity and frequency will be evaluated to determine the proper course of detox and treatment.9

Withdrawal Symptoms & Complications

After repeatedly using drugs or alcohol, a person’s body may become physically dependent on that substance to function optimally. If a dependent person abruptly stops drinking or taking drugs, they could experience very uncomfortable, painful, and potentially life-threatening withdrawal symptoms.3

These symptoms vary by substance, but they typically include both physical and psychological effects. Some symptoms, such as seizures associated with alcohol and benzodiazepine withdrawal syndromes, can be very harmful and even fatal. Other symptoms, such as nausea and vomiting, which are associated with various substance withdrawal syndromes, can be distressing, but not typically fatal. Withdrawal symptoms can make it even more difficult for an individual to quit abusing substances, because many people relapse in order to alleviate the unpleasant symptoms and cravings.3

Seeking help for addiction.Having PTSD and a co-occurring substance addiction can complicate withdrawal and recovery. Many researchers have suggested the self-medication theory for why substance abuse commonly co-occurs with PTSD. Using drugs or alcohol is often an attempt to alleviate some of the distressing symptoms associated with PTSD.9,11 In a review of PTSD and substance abuse comorbidity, researchers found that substance use, PTSD, and relapse risk occur in a cyclical pattern that is extremely difficult to break. After prolonged substance use, the person might stop using and immediately have a difficult time dealing with the withdrawal symptoms, along with the amplified symptoms of PTSD and severe cravings. Thereafter, they might relapse, causing the cycle to begin again.11 To further complicate this comorbidity, substance withdrawal symptoms, such as insomnia, detached feelings, irritability, and concentration problems, can often resemble PTSD symptoms.9 This may serve as further reinforcement to self-medicate as a means of coping with PTSD symptoms.9

Furthermore, in a recent research review, the authors reported that withdrawal from many substances of abuse can negatively impact memory and stress responses. Stress and memory problems, which are issues associated with both withdrawal and PTSD, can trigger relapse in those who struggle with drug or alcohol abuse. People with PTSD commonly have complicated responses to stress and memory issues, which can be compounded by experiencing similar symptoms during substance use withdrawal. For a person with PTSD, the difficulty in managing these synergistic stressors during withdrawal can be intense.12

Professional detox programs help manage substance withdrawal symptoms alongside PTSD symptoms and can keep a person safe in these potentially dangerous circumstances. When a person begins to go through detox and drug withdrawal, medical staff need to be present to support him through the process while also monitoring the symptoms and medications used to treat any underlying mental health disorders.10, p.136-7 For people with PTSD, medical professionals aid in the monitoring and treatment of psychiatric issues during detox and subsequent treatment programs. This is essential, as ignoring the mental disorder during detox can predispose a patient to relapse.10, p.136, 4th paragraph

Detox Options for Co-Occurring Disorders

Detoxification is designed to help a person achieve a drug-free state and includes a “set of interventions aimed at managing acute intoxication and withdrawal.”10 Detox services may be found in several different types of programs, with the two main settings being inpatient and outpatient. Inpatient requires that you live at the detox facility for the duration of the program; staff members provide you with 24-hour support, care, and monitoring to ensure your safety. Inpatient is the recommended detox level for those with a dual diagnosis, due to possible complications and severity of withdrawal symptoms.10

There are two common models of inpatient detox—medical and social. They both offer around-the-clock detox services, but only medical detox provides medical care and medication, if applicable, to enhance your comfort and safety throughout the withdrawal process. Social detox relies more heavily on emotional and psychiatric support and may have to transport you to a hospital in the event of a medical emergency.10 Inpatient medical detox is the safest detox option for someone struggling with an addiction and PTSD.

There are three main components of detoxification. They include:

  • Evaluation: This involves testing for various substances present in the bloodstream and screening for co-occurring psychiatric and medical conditions. The mental health professional uses this information to determine an appropriate detox treatment plan for you.
  • Stabilization: This is when actual detoxification occurs, with the aid of several medical and psychiatric interventions. If applicable, withdrawal medications are used to ease withdrawal symptoms and cravings. The goal of detox is to achieve a medically stable state, free of substances.
  • Transition into addiction treatment: Once you’re stable and abstinent at the completion of the detox period, the treatment team will help to enhance your motivation for transitioning into a dual diagnosis program. They will create a plan and referral for you to enter the best dual diagnosis treatment program for you.

Getting consulted before enrolling into a detox program.The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends that a detox facility use a team approach of coordinated care, so your detox treatment team and other providers (e.g., your primary care physician) can work together to aid in your detox process and provide support for withdrawal and PTSD symptoms.10

PTSD comorbidity with a substance use disorder usually comes with additional medical ailments and emotional complexities.9 While outpatient care is possible, inpatient detox provides you with 24-hour support and treatment designed to address some of the common psychosocial and physical consequences of PTSD-specific dual diagnosis, such as:9

  • Increased risk of violence.
  • Increased rates of suicide attempts.
  • Chronic medical problems.
  • Worse adherence to treatment.

Inpatient detox can help to mitigate some of these risks and make sure that you safely withdraw from the substance or substances you’re addicted to while receiving psychiatric support for PTSD.

Continuing with Care

Detox is only one part of a continuum of care for substance-related disorders and should be followed by additional substance abuse treatment.10 Substance abuse rehabilitation continues after detox completion. While protocols will vary, all rehab programs will implement a set of therapeutic interventions and services to help you progress through your recovery from substance abuse and best achieve lasting sobriety. In the event of co-occurring PTSD and addiction, a dual diagnosis treatment program will be the most appropriate rehabilitation option. Not all rehab centers specialize in dual diagnosis treatment, so you’ll want to do your research and find a program that can adequately address all of your treatment needs.

About 50% of the people that enter inpatient treatment for substance abuse also meet criteria for having PTSD as a co-occurring disorder.11 Studies of people with PTSD and a co-occurring substance addiction have shown a benefit for concurrently treating both substance abuse and PTSD, which is commonly referred to as integrated treatment.9 Integrated treatment for dual diagnosis requires collaboration between all treatment professionals, such as addiction counselors, medical doctors, and trauma therapists.13

Prior to creating a dual diagnosis treatment plan, the treatment team must examine the relationship between the addiction and the PTSD symptoms of the recovering individual. Self-reports documenting why a patient abuses substances (e.g. to improve sleep, to forget trauma-related memories, to decrease anxiety surrounding social interactions, etc.) can be utilized to guide treatment planning.9 The most effective integrated treatment plans are patient-centered, addressing the patient’s goals and using treatment methods that are appropriate for their individual needs.13

Integrated treatment is associated with better outcomes including:13

  • Decreased drug and alcohol abuse.
  • Increases in psychiatric functioning.
  • Improved quality of life.
  • Fewer arrests.
  • Decreased hospitalization.
  • Increased housing stability.

Group therapy to overcome addiction.The integrated treatment model functions under the notion that addressing the traumatic event or events in the early stages of rehab and improving PTSD symptoms will likely enhance the addiction recovery process.9

PTSD treatments are sometimes based on the particular substance abused. For instance, studies have found that people who abuse cocaine and have PTSD benefit from exposure therapy. This type of therapy uses desensitization techniques to help patients develop coping skills.14 Seeking Safety (SS) is another treatment for PTSD comorbidity. Specifically, it is a treatment model designed for trauma and substance abuse disorders focused on building coping skills through psychoeducation.14

Evidence-based help and experienced support are available to people dealing with PTSD and substance use disorders. If you are ready to make a positive step toward substance abuse and PTSD recovery, you should consider enrolling in a dual diagnosis detox or rehab program.

Sources

  1. Abou-Saleh, M. T. (2004). Dual diagnosis: Management within a psychological context. Advances in Psychiatric Treatment (2004), 10, 352–360.
  2. National Institute on Drug Abuse. (2018). Common comorbidities with substance use disorders: What are some approaches to diagnosis?
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  4. National Center for PTSD. (2015). Symptoms of PTSD.
  5. National Institute on Drug Abuse. (2018). Common comorbidities with substance use disorders: Why is there comorbidity between substance use disorders and mental illness?
  6. National Institute on Drug Abuse. (2018). Common comorbidities with substance use disorders: Introduction.
  7. Substance Abuse and Mental Health Services Administration. (2017). Mental and substance use disorders: Co-occurring mental and substance use disorders.
  8. National Institute on Drug Abuse. (2018). Common comorbidities with substance use disorders: Part 1, the connection between substance use disorders and mental illness.
  9. McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co-occurring substance use disorders: Advances in assessment and treatment. Clinical Psychology, 19(3), 10.
  10. Substance Abuse and Mental Health Services Administration. (2015). Detoxification and substance abuse treatment.
  11. Souza, T. & Spates, C. R. (2008). Treatment of PTSD and substance abuse comorbidity. The Behavior Analyst Today, 9(1), 11-26.
  12. Tipps, M. E., Raybuck, J. D., & K. Lattal, K. M. (2014). Substance abuse, memory, and post-traumatic stress disorder. Neurobiology of Learning and Memory, 112(0), 87–100.
  13. Substance Abuse and Mental Health Services Administration. (2017). Behavioral health treatments and services.
  14. National Institute on Drug Abuse. (2018). Common comorbidities with substance use disorders: What are treatments for comorbid substance use disorder and mental health conditions?

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