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Veterans, PTSD, and Drug Abuse

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Military veterans are at a higher risk of developing post-traumatic stress disorder (PTSD) than the general population, since many in this group have experienced deployment to war zones or exposure to combat. PTSD is linked to an increased risk of substance use and abuse, a combination of conditions suited for what’s known as dual diagnosis treatment.1,2,3

Among veterans who served in Vietnam and later wars, 41.4% who had a substance use disorder were also diagnosed with PTSD.2 In fact, research shows that more than 20% of veterans with PTSD also have one or more substance use disorders, and one national study suggests that as many as 76% of veterans have these co-occurring disorders.4,5

Many people understand this connection, but it wasn’t always the case. The identification and understanding of PTSD has changed dramatically within the last century, as have the techniques that are used to effectively treat it.

For a long time, scientists did not make the connection between PTSD and substance abuse. One theory is that studies conducted in previous decades to determine if veterans suffered from PTSD or substance use employed self-reporting techniques, and trauma-related symptoms may have been less likely to be reported in the past.1 Also, veterans may not be willing to report issues or may be reluctant to seek treatment from the Veterans Administration (VA) for several reasons, such as:6,7

  • For fear of being treated differently than their peers.
  • Concerns about privacy.
  • A perceived stigma of weakness.
  • A lack of confidence in treatment.
  • Worry that it may jeopardize their position or ability to receive future promotions.

PTSD: Then and Now

PTSD develops after exposure to a traumatic event that triggers feelings of terror, horror, or powerlessness, like those often found in war zones.2 The likelihood of veterans developing PTSD is increased relative to the severity of their exposure to warfare.2 And the changing nature of modern warfare, such as prolonged wars and unpredictable factors like improvised explosive devices, creates additional stressors that can place veterans of recent wars at an increased risk of developing PTSD and drug abuse.3

This increased risk of developing PTSD among active military personnel can also be attributed, in part, to:3

  • Needing to be constantly vigilant about the danger around them.
  • Living with a constant and real risk of being killed or hurt.
  • Seeing others injured or killed during combat.
  • Having to hurt or kill others.

Additional factors that contribute to their odds of getting PTSD include:3

  • Extended time deployed to combat zones.
  • Severity of exposure to war, such as being closer to the front lines, or seeing others hurt or killed in combat.
  • Severe physical injuries or traumatic brain injuries.
  • Decreased social support within the armed forces and from family, spouses, or friends outside the military.
  • Prior exposure to trauma.
  • Being a member of the National Guard or Reserves, who may be unexpectedly deployed for long periods of time.
  • Lower ranking in the military.

Common symptoms of PTSD fall into 4 categories that include:3,8

  • Flashbacks: Reliving traumatic events through nightmares or memories, which can make you feel as if you are experiencing the trauma all over again.
  • Avoidance: People with PTSD may avoid talking about the trauma, try to block it out, or avoid people, places, or things that are reminiscent of traumatic events. For instance, veterans with PTSD may avoid watching movies or shows about war or discussing topics involving war.
  • Changes in how you view yourself or others: Thinking and feeling more negatively about yourself or others is commonly experienced in veterans with PTSD. Feelings of guilt or shame, lack of interest in hobbies, difficulty experiencing positive emotions such as happiness or love, difficulty trusting others, or feeling numb to emotions are all associated with the disorder.
  • Hyperarousal or hypervigilance: This can manifest in feeling overly alert due to experiences in combat; struggling to focus or sleep; having an overly active startle response; irritability or anger; or engaging in risky or unhealthy behaviors such as reckless driving, substance use, or smoking cigarettes.

Veterans with PTSD may also develop depression, anxiety, substance use disorders, or chronic pain. And, symptoms of PTSD can contribute to difficulty maintaining relationships or employment.8

Although symptoms of PTSD have been recognized since ancient times—the book of Deuteronomy in the Old Testament refers to soldiers having to be displaced from the front lines of battle due to nervous breakdowns, which, at the time, was believed to be contagious—it wasn’t until the 1980s that there was a scientifically accepted diagnosis.9 From the late 1800s to the early 1900s, PTSD symptoms were referred to by a variety of names, including “traumatic neurosis,” “combat hysteria,” and “war neurosis.”9

During World War I, the term “shell shock” was coined to describe soldiers suffering from mental disorders caused by emotional distress from seeing fellow soldiers killed or severely injured or as a response to artillery shells exploding nearby. The majority of these soldiers did not suffer physical wounds themselves.9,10 At this time, people began to recognize that stress endured during combat could cause mental health issues.9

In the early 1950s, the American Psychiatric Association produced the first formalized diagnosis of PTSD, called “gross stress reaction,” which referred to normal people suffering from symptoms that resulted from trauma. This diagnosis was expected to resolve within 6 months or a different diagnosis would be issued.10 During and after the Vietnam War, nearly a quarter of veterans serving between 1964 and 1973 required psychological treatment.9

The term “Post Traumatic Stress Disorder” was introduced as a diagnosis by the American Psychological Association in 1980 after extensive research with Vietnam veterans, Holocaust survivors, and people who had experienced sexual trauma. Researchers were able to demonstrate a link between combat-related trauma and the reintegration into a civilian lifestyle (in the case of military members), along with a formalized description of PTSD symptoms.10

PTSD is currently recognized as varied in its manifestation, although most veterans experience a period of latency, in which symptoms do not appear until after the trauma has ended.9 The diagnosis cannot be made unless symptoms persist for at least one month and interfere with your daily functioning or cause you substantial distress.10 Once symptoms do present, PTSD most commonly will follow a chronic time-course and generally does not improve unless you receive treatment.9

Currently, the military recognizes the importance of screening veterans and active duty military personnel for PTSD and provides specialized treatment.10 The VA has become committed to treating PTSD using highly effective, research-proven methods, often training treatment providers in the most up-to-date therapeutic approaches.6,10 In 2013, more than 5,000 clinicians received training to treat PTSD at VA facilities.10

PTSD and Drug Abuse

While there are several theories surrounding the connection between PTSD and the development of substance use disorders in veterans, currently the widely accepted theory is that veterans use drugs or alcohol to self-medicate distressing symptoms. Studies have demonstrated that the substance used is correlated with the type of symptoms most prominently experienced. For example, veterans suffering from symptoms of hyper arousal are more likely to abuse depressants like alcohol in an attempt to reduce those symptoms.2 And stimulants like cocaine may be used more by veterans with symptoms of depression like negative thoughts and lethargy.

In veterans with PTSD who also use substances, drug or alcohol cravings may increase as PTSD symptoms increase, providing more evidence to support the self-medicating theory.2 Additionally, certain symptoms of withdrawal can mimic some of the symptoms of PTSD, leading some people to use again to alleviate the discomfort these symptoms cause.4

Veterans with both an alcohol use disorder and PTSD are also more likely to binge drink, possibly in periodic attempts to block out traumatic battle memories or flashbacks. Counter productively, substance use may actually prolong the duration of PTSD by providing an escape from the trauma, which cannot be treated successfully if the person is actively avoiding it.4

Substance use alters a person’s ability to perform well physically and mentally, and it can impair a soldier’s ability to do their duty or even lead to legal sanctions if they are using illegal drugs or driving under the influence. Medical, social, financial, and legal consequences are commonly associated with substance abuse, in general, and in the military, there is a zero-tolerance policy for substance use, with active soldiers frequently drug tested.2,4,11 Positive drug tests in the armed forces may lead to criminal charges and dishonorable discharge.11

Veterans with PTSD who abuse substances often experience an exacerbation of physical health issues or cognitive impairment in their day-to-day civilian lives.2,11 These veterans are at increased risk of other issues, too, including domestic violence, sleep disturbances, and severe depression.11 Substance use has been involved in almost 30% of suicides for active soldiers in the Army between the years of 2005 and 2009.11

Treating Veterans

In World War I, soldiers who experienced mild cases of shell shock were allowed to rest for a few days before returning to the front lines. More severe cases of shell shock were treated by removing soldiers from combat areas and sending them to specialized hospitals where they were expected to rest and focus on successful reintegration into civilian life. Some European hospitals used hydrotherapy or shock treatment combined with hypnosis to treat this disorder.10

In efforts to reduce the loss of soldiers, forward treatment was implemented, which is when soldiers were treated near the combat zones to allow for social support from their military peers while focusing on returning to battle as soon as possible.9 During World War II, the terminology was changed from “shell shock” to “battle fatigue” or “combat stress reaction” and forward treatment allowed 50 to 70% of sufferers to return to combat.9 Nearly half of all military discharges during World War II were due to combat exhaustion, and long-term studies were conducted to determine its effects.9,10

During the Vietnam era, forward treatment was still used to treat soldiers with symptoms of what is now known as PTSD.9 Levels of substance use were also high among service personnel during this time, and as veterans returned home, they were drug tested and sent for rehabilitation as needed.9,11

As the knowledge surrounding PTSD and substance use expanded, the VA began to focus on treating both disorders at the same time.2,4,5 This is known as the integrated model of treatment and has been shown to be effective due to the complex interplay between PTSD and substance abuse.2,4,5 As of 2010, the VA has shown a commitment to making the most effective treatments available to veterans with PTSD and substance abuse.5

Integrated treatment uses:2,4,5

  • Education.
  • Cognitive behavioral therapy (CBT): A therapeutic approach that emphasizes the connection between your thoughts, feelings, and behaviors, and learning how to adjust them toward healthier outcomes.
  • Cognitive processing therapy (CPT): A type of trauma-based psychotherapy that teaches patients to reframe their thoughts about a situation to help resolve distressing feelings.
  • Medication, as needed.

These treatments all focus on helping veterans learn positive coping skills to manage their symptoms and emotions surrounding the trauma that contributed to the development of their PTSD.2

Treating veterans comes with unique challenges, and the VA has invested a large amount of resources into educating and training for clinicians to treat veterans in the most effective way possible.2,4,5 Discussing the traumatic experiences associated with combat can be difficult to address in groups with civilians, and there is a unique culture and need among veterans for treatment with providers who understand this lifestyle.7

The first step in seeking PTSD and substance use treatment for many people is attending a detoxification facility. Substance use has the effect of numbing or avoiding trauma, which cannot be addressed until the substance use has stopped.4 Detox services are available through the VA, in civilian facilities, or on an outpatient basis in some cases. It is important receive supervision in one of these settings, since withdrawal can worsen the symptoms of PTSD and increase cravings. The staff at detox programs can provide support and medications to ease the discomfort associated with the withdrawal process.

Once detox is complete, behavioral techniques and medications can be used to further recovery from both issues in extended treatment options. For veterans who need a more structured setting to recover from substance use and PTSD, the VA offers residential treatment programs or transitional programs to ease the reintegration into a sober, civilian lifestyle.6

Recovery is possible with the right treatment and support, and the VA has actively worked to reduce the stigma surrounding substance use and mental health issues and to improve confidentiality to better serve our country’s veterans.11

Sources

  1. Hourani, L.L., Williams, J., Bray, R.M., & Kandel, D.B. (2014). Posttraumatic stress disorder, substance abuse, and other behavioral indicators among active duty military men and women. Journal of Traumatic Stress Disorders and Treatment, 3(3), 1–7.
  2. 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: A Publication of the Division of Clinical Psychology of the American Psychological Association, 19(3), 1–27.
  3. U.S. Department of Veterans Affairs. (2015). Mental health effects of serving in Afghanistan and Iraq.
  4. U.S. Department of Veterans Affairs. (2015). PTSD and substance abuse in veterans.
  5. U.S. Department of Veterans Affairs. (2017). Treatment of co-occurring PTSD and substance use disorder in VA.
  6. Pickett, T., Rothman, D., Crawford, E.F., Brancu, M., Fairbank, J.A., & Kudler, H.S. (2015). Mental health among military personnel and veterans. North Carolina Medical Journal, 76(5), 299–306.
  7. Substance Abuse and Mental Health Services Administration. (2014). Veterans and military families.
  8. U.S. Department of Veterans Affairs. (2016). What is PTSD?
  9. Crocq, M-A. & Crocq, L. (2000). From shell shock and war neurosis to posttraumatic stress disorder: A history of psychotraumatology. Dialogues in Clinical Neuroscience, 2(1), 47–55.
  10. U.S. Department of Veterans Affairs. (2017). History of PTSD in veterans: Civil War to DSM-5.
  11. National Institute on Drug Abuse. (2013). Substance abuse in the military.

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