Running head: WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION?

What is the relationship between PTSD and Addiction?

Lyndzie L Vogelzang

Parkland College
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 2

Abstract

There is evidence both supporting and disproving that PTSD (post-traumatic stress disorder) and

addiction are co-occurring. With multiple theories including disinhibition, emotional regulation

or compulsive re-exposure and multiple types of PTSD and multiple types of addictions the

evidence for addiction and PTSD are varied and interwoven that rely on multiple variables. This

study on peer-reviewed information collects and debates whether PTSD and Addiction are co-

occurring disorders or if they are presently based on other factors.

WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 3

Introduction

What is the relationship between PTSD (Post Traumatic Stress Disorder) and Addiction?

In Dworkin et al.’s 2018 study about PTSD presentation in different substance addictions the

focus of the study was about the differences of PTSD symptom reaction with either Cocaine,

Alcohol, Opioids, Cannabis, Sedatives or a combination of the substances. According to initial

research for Dworkin et al.’s study by Jacobsen, Southwick and Kosten in 2001 PTSD are

prevalent in SUD (substance use disorder) patients. The focus of Kok et al.'s 2015 study was

about how the prevalence of PTSD symptoms in SUD patients and how the treatment of patients

with both PTSD and SUD's complicates treatment. Kok et al. references multiple studies

(Ouimette et al., 2005; Reynolds et al., 2005; Kimerling et al., 2006; Driessen et al., 2008; Kok

et al., 2012) about the frequency of PTSD in SUD inpatients; these ranges are reported at 25-

51% and outpatients reporting 8-27 % (Graybill et al., 1985; Clark et al., 2001; De Bellis, 2002;

Mills et al., 2006; Najavitis et al., 2007; Schneider et al., 2007; Driessen et al., 2008) onto which

the study was based. Saunders et al.' 2015 study of PTSD symptoms in addicted cocaine patients

focus, much like Kok et al.'s study, on the negatively impacted treatment successes of addictions

when the trauma is present. They quote other research stating that 23-42% of cocaine using

peoples diagnosed with PTSD that will last a lifetime (Back et al., 200; Halikas et al., 1994;

Magura et al., 1998; Wasserman, Havassy & Boles, 1997). In a study about PTSD

symptomology in addicted women smokers that was researched in 2014 by Young-Wolff et al.

the research focused on how this information would change between genders as most PTSD

addiction studies have focused on veteran males (McFall et al., 2005; 2006; 2010). Young-Wolff

et al. also state that there are studies that show women have a higher chance of PTSD than their
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 4

male counterparts (Olff et al., 2007; Pietrzak et al., 2011; Tolin & Foa, 2006; Compton et al.,

2007; Grant et al., 1997; Kessler et al., 2005).

Lit Review

In Dworkin et al. (2018) study of addiction and substance abuse investigated why people

who were diagnosed with both PTSD and SUD's use the specific substance of choice; are they

using the substance to treat PTSD symptoms? The hypothesis that Dworkin et al. had was that

the subjects were using the substance to either reexperience, numb, or be hyper-aroused to treat

their trauma (Khantzian, 1985; Stewart, 1996; Possemato et al., 2015). In Young-Wolff et al.,

2014 study they also mention that SUD’s could be a response to PTSD’s as a form of self-

medication (Fu et al., 2007; Feldner et al., 2007). There is also documentation in the study

(Saunders et al., 2015) that addicts may have started using the substance to cope with the trauma

(Johnson et al., 2010; Tull et al., 2010)

There is also documentation that across different substances there are different PTSD

system responses (Dworkin et al., 2018) (Avant, Davis, & Cranston, 2011; Khoury, Tang,

Bradley, Cubells, & Ressler, 2010; Avant et al., 2011). This information is also reported in all the

reviewed studies Kok et al., 2015 study (Mirsal et al., 2004), Young-Wolff et al., 2014 study

(Olff et al., 2007) and Saunders et al., 2015 (Riezzo et al., 2012; Lange & Hillis 2001). Those

responses depend on drug type and system response- reexperience, numbing or hyperarousal

(Dworkin et al., 2018). There is also documentation on this information (Saladin, Brady, Dansky

& Kilpatrick., 1995) specifically about cocaine and its responses that correlate with Saunders et

al. (2015) study focusing on cocaine’s interaction with PTSD.

WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 5

In Saunders et al. (2015) study of the prevalence of PTSD in addicted cocaine users, the

researchers focused on the drug cocaine because of the high addiction rate within the United

States with reported use of 1.1 million addicts (SAMHSA 2013). This is pertinent information as

the use of this drug is associated with both negative physical and mental issues including a

likelihood of increased criminal involvement (Riezzo et al., 2012; Lange & Hillis 2001). This

could be a marker as to why the relationship with addiction and PTSD could be substantial as

traumas are more likely to happen in unsafe situations (Saunders et al., 2015) (Brady et al., 1998;

Dansky et al., 1996).

Another theory mentioned in the Saunders et al. (2015) study is that poor therapy

outcomes of addicted PTSD patients may have to do with the interaction of the drug and the

trauma, with studies using cocaine showing a severity difference when using the drug (Brady et

al., 1998; Freeman, Collier & Parillo, 2002) and improved responses when the drug use lessened

or diminished (Back et al., 2006; Bremmer et al., 1996).

In Saunders et al. (2015) study there is documentation of females having worse reactions,

in terms of dependence on the substance cocaine, that connects with Young-Wolff et al., 2014

study about PTSD addicted women (Chen et al., 2011; Najavitis & Lester 2008; Stecker et al.,

2007) as the study is only looking for information on women as most studies dealing with

addiction and PTSD have been focused on male reactions (McFall et al., 2005; 2006; 2010).

In Young-Wolff et al. (2014) about addicted female smokers, the reported number of

PTSD diagnosed patients who also were addicted smokers was 45% of the tested population

(Lasser et al., 2000). There was also a reported greater chance of PTSD patients being addicted

to nicotine and tobacco usage as they have up to 5 times greater risk than a non-PTSD person (Fu

et al., 2007). As there is are severe negative physical responses to cigarette usage (Beckham et
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 6

al., 1997; Deykin et al., 2001) and a higher risk of PTSD in women (Olff et al., 2007; Pietrzak et

al., 2011) the focus of this study was addicted smoking women who had PTSD symptomology

and the chance of addiction recovery if the PTSD and addiction were treated simultaneously.

In Kok et al. (2015) study they quote previous research by stating that 90% of addicts

classified as having Substance Abuse Disorder (SUD) will experience trauma, this however will

not cause them to have PTSD (Triffleman et al., 1995; Najavitis et al., 1997; Farley et al., 2004).

There is also reported data stating that SUD patients receive more severe trauma than the general

population (Khoury et al., 2010). There is a study they quote that states that exposure the trauma

may cause a SUD, so this claim is disputed (Kilpartick et al., 2003; Sartor et al., 2007).

While the previous studies did not claim that PTSD and addiction are co-occurring, the

alternative side claims evidence with studies by Contractor et al. (2017), Hsieh et al. (2016),

Jayawickreme et al. (2012), and Mitchell et al. (2016).

Contractor et al. (2017) study was concerning PTSD symptoms and smartphone

addiction. They quote previous information on the co-occurring aspect of both PTSD and

addiction (Breslau, 2009) and that impulsivity (addictive personalities) are related to PTSD

severity (Contractor, Frankfurt, Weiss & Elhai, 2017; Weiss, Connolly, Gratz & Tull, 2017).

Contractor et al. (2017) also mention that smartphone usage has been categorized as a

non-chemical addictive behavior through the studies of Billieux, (2012); van Deursen, Bolle,

Hegner & Kommers (2015). Contractor et al. (2017) refer to information on the addiction by

referencing a 2009 study by Ezoe et al. saying that there are habitual overdoses as well as

functional impartment and this behavior includes a withdrawal period as well. This addiction has

real-world effects as the use of a device while driving is commonly lethal as driving becomes

impaired (Violanti, 1998).

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Contractor et al. (2017) refer to the theory of co-occurring PTSD in regards to 3 main

theories: disinhibition, emotional regulation or compulsive re-exposure. Disinhibition is the

belief that those who have PTSD have poor compulsivity that would put them at risk for

dangerous situations as they are more likely to risk for rewards (Casada & Roache, 2005).

Emotional regulation is the belief that those with PTSD will put themselves in impulsive

situations to reduce negative feelings that are in regards to their trauma (Marshell-Berenz,

Vujanovic, & MacPherson, 2011). Compulsive re-exposure is the belief that those with PTSD

will put themselves in highly stimulating situations to re-achieve the bodies natural high from the

traumatic event (Joseph, Dalgleish, Thrasher & Yule, 1997; Van der Kolk, Greenberg, Boyd &

Krystal, 1985).

Hsieh et al. (2016) study was about internet addiction in adolescent Taiwanese students

who had past maltreatment and PTSD. They quote documentation staying that maltreatment is

one of the leading causes of behavioral problems such as internet addiction (American

Psychological Association Committee on Professional Practice and Standards, 1998). There is

also research that includes child mistreatment with both substance and behavioral addictions

(Kural & Cakmak, 2006; Hodgins et al., 2010). The only behavioral study found that included

internet as the behavioral addiction was by Yates, Gregor, and Haviland in 2012. As so few

numbers of studies involving internet addiction and its relationship with trauma have been

performed (Chen, Chen, & Gau, 2015; Ko, Yen, Yen, Chen & Chen 2012) the focus of this study

will be on how different types of childhood traumas will impact the usage of internet. There is a

large population of Taiwanese students who have a higher chance of PTSD as they have

experienced trauma in the form of neglect (Shen, 2009).

WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 8

Jayawickreme et al. (2012) were focused on how female and male individuals who have

both PTSD and addiction would differ. Research for this study showed that while 75% of the

general population in the United States will experience a traumatic event, only 6.7% will report

having PTSD (Sledjeski, Speisman, & Dierker, 2008). Of the PTSD population, 32.7% will

report having used a substance or abusing a substance (Sledjeski et al., 2008) and 10.3% of

males will report using alcohol as a dependent versus the 26.2% of women who would claim the

same (Kessler et al., 1997). This relates to the high prevalence of those who have AD also

reporting PTSD symptomology (Najavitis, Weiss & Shaw, 1997; Langeland & Hartgers, 1998).

Jayawickreme et al. (2012) also report that there is a documented gender difference when

looking at the amount of diagnosed PTSD patients with a traumatic event being 75% more likely

to be a woman (Sledjeski et al., 2008). However, in the observance of alcohol dependence study,

men were twice as likely to have criteria matching PTSD symptomology than women (Harford,

Grant, Yi, & Chen, 2005). There is little documentation of co-morbid alcohol dependence and

PTSD symptoms where the focus of the study is on how the gender of the participant effects the

symptoms of both disorders (Sonne et al., 2003). There is some documentation showing that men

will likely be more prone to use alcohol to alleviate PTSD symptoms where women are more

likely to use avoidance (Sonne et al., 2003).

Mitchell et al. (2016) study was focused on PTSD and food addiction in older veterans.

The research they quote states that often the cause of an eating disorder is childhood trauma

relating highly to sexual abuse (Jacobi et al., 2004). PTSD patients are also at high risk for PTSD

as it could be the body's natural response to trauma as to create control over a situation

(Brewerton, 2007; Mitchell et al., 2012). There is also documentation showing high percentages

of people who had an eating disorder also had a history of PTSD (Mitchell et al., 2012). These
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 9

percentages range from 40-60% for bulimia and 24-26% for binge eating (Mitchell et al., 2012).

This study also mentioned emotional regulation as a possible cause for this behavior similar to

Contractor et al. (2017) study (Corstorphine et al., 2007; Svaldi et al., 2012, 2010). Emotional

regulation has been affiliated with PTSD as due to the misunderstanding of communication

between what the brain is evaluating and what the PTSD is reacting to (Gross, 2014; Ehlers and

Clark, 2000; Kasdan et al., 2010).

Mitchel et al. (2016) connect to Jackawikreme et al. (2012) study on gender differences

in PTSD by showing that women whom also have eating disorders (ED) are more likely to be

avoidant emotionally than those who do not have the disorder (Svalidi et al., 2012). There is

documentation stating that the relationship between PTSD and ED is similar to that of PTSD and

SUD as both are maladaptive methods of coping with PTSD (Gearhardt et al., 2009). It is also

important to know that there are those who do not believe that an addiction to food is possible

stating that there is not enough information to claim food can be addicting (Hebebrand et al.,

2014). This contradicts the study showing that the eating of high fat and sugar foods activates the

same pathways in the brain that highly addictive substances also activate (Gearhardt et al., 2011).

Discussion

In Dworkin et al. (2018) study of the symptomology of PTSD in SUD patients, the

information gained contradicts previous literature on SUDs as those whom have PTSD were

more likely to use avoidance than their non-traumatized group. There was a strong correlation

between cocaine usage or alcohol usage and hyperarousal (Dworkin et al., 2018). The

researchers concluded that this study's hypothesis would be most similar to the self-medication

or mutual maintenance theories that relate PTSD to addiction. This was concluded as cocaine
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 10

usage increased the PTSD symptoms either to re-experience the trauma or to numb the trauma

(Dworkin et al., 2018). As the participants in this study had used their substance of choice within

the last three months, there could be evidence showing co-occurring disorders. The researchers

conclude that addiction and PTSD will differentiate over each substance making a case for full

co-occurrence hard to state (Dworkin et al., 2018).

In Kok et al. (2015) study of PTSD symptoms in addicts, the study was inconclusive as

many of the variances where high. Reported information states that age had a significant role

with alcohol-dependent patients especially if the trauma happened at a younger age.

In Saunders et al. (2015) study of PTSD symptoms in addicts, the study reported that of

the highly Caucasian, younger (35) male population tested that 42% would have PTSD

symptoms. Of the percentage, 66% would have moderate PTSD, and 33% would have severe

PTSD. The substance that was tested for was cocaine with 157 of the participants using more

than cocaine and only 2 using cocaine exclusively. This information may add to previous

literature stating that cocaine usage and PTSD are highly related (Saunders et al., 2015). Adding

to the literature reviewed (Dworkin et al., 2018; Young-Wolff et al. 2014) there is a stronger

association with the female addict and PTSD in comparison to male addicts. The researches

acknowledge limitations on this information as it has a cross-sectional design, limited histories

on participants, and a similar testing field.

In Young-Wolff et al. (2014) study of PTSD symptoms in addicted smoking women, the

testing field contained 43% documented PTSD women. This percentage also had increased SUD,

overall more drug usage, and poorer mental health. However, those who had PTSD were more

willing to quit their substance than those who did not. This relates to prior literature stating that

interventions can positively improve the treatment of PTSD with addiction when acknowledging
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 11

the addiction in the treatment plan. This may be because of the informed patient being made

aware of the correlation between PTSD and addiction will be more likely to address their trauma

earlier and avoid situations that would include the use of their substance.

In Contractor et al. (2017) study of PTSD’s relationship with Smartphone usage, the

results suggest that having poor impulse control or poor attention may relate to the severity of

PTSD. There is also documentation showing that addictive smartphone usage is related both

separately and together when experiencing negative emotions (Contractor et al., 2017). This adds

to other documentation of PTSD interactions with addictive behaviors showing poor impulse

control and negative urgency with the addictive substance. This information is inconsistent with

what Contractor et al. (2017) theorized, as tedious tasks where likely to be abandoned but the

addictive smartphone behavior was rarely reported on changing. This may suggest that the

problem deals more with impulsivity than addiction (Contractor et al., 2017). This contradicts

studies done with younger populations (Contractor et al. (2017) average age being 33) done by

Contractor et al. in 2016 with college-aged participants that showed significant correlations in

the PTSD symptomology and avoidance and/or lack of perseverance.

Contractor et al., (2017) mentions limitations of the study including that the information

is all self-reported meaning that it could be biased. This form of self-reporting also was internet

based meaning that there was no control over the testing environment or who self-chose the

questionnaire. Contractor et al. (2017) reminds us that the self-reporting system used known as

Amazon's Mechanical Turk (Mturk) program is documented (Buhnmester et al., 2011) to be

demographically diverse even when compared to other internet sources (Mischra & Carleton,

2017) and proves reliable on data reported (Buhnmester et al., 2011; Shapiro et al., 2013).

Contractor et al. (2017) does mention that as the data is cross-sectional, biases can form. There is
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 12

also a chance that mental disorders that were not looked for could have been present skewing

results as well as an updated questionnaire that could have been used (Contractor et al., 2017).

In Heish et al. (2016) study about Taiwanese children who have been abused and their

addiction to the internet, there was a relationship with those who had recently been abused who

had PTSD and those who had maltreatment PTSD with the amount of internet addiction

measured. The study showed that the children might be using the internet as an escape to deal

with PTSD symptoms much like how adults are using substances to do the same behavior (Heish

et al., 2016). The study showed multiple consistent associations with maltreatment and its effect

on the addiction. While the researches hypothesis thought that violence would be prevalent as a

behavioral action, that was proven to be inaccurate in this study (Heish et al., 2016). Limitations

on this study include bias as the report was self-evaluations, that this was a cross-sectional study

and as such could draw conclusions that were not there and that this is a first generation study.

In Jayawickreme et al. (2012) study about gender differences with PTSD and addiction

used multiple self-reported questionnaires to gather information. This study than reported that

similar to past documentation, addicted men (alcohol) would have negative beliefs, self-worth

and blame themselves for the trauma. This information also might show a correlation as to why

men report a higher craving for the drug as they use it as a coping tool(Jayawickreme et al.,

2012). Women do not share the negative self-beliefs like men but, do often blame themselves for

the trauma and avoid possible loss of orientation (that alcohol may provide). Limitations on this

study may include bias in self-reported data, no one that was highly addicted and that the study

was primarily male (Jayawickreme et al., 2012).

In Mitchell & Wolf’s (2016) study if PTSD and food addiction, the results correlated with

previous documentation that showed a correlation between eating disorders (ED) and PTSD.
WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 13

This study adds more information to male sufferers of ED as most documentation has been

female. This adds value as most ED were thought to originate through childhood trauma, but the

veterans who were suffering from the ED stated that their symptoms started after adulthood

expanding on previous beliefs (Mitchell & Wolf, 2016). Contrary to the original hypothesis, the

beliefs and suppressions thought to be in the veterans were not present. This is important as the

original hypothesis stated that a dysregulated emotional state would be responsible as both are

present in PTSD and ED. The researchers acknowledge that the information was limited in

multiple ways (Mitchell & Wolf, 2016).

Implications and Conclusions

All of these studies show strong relationships between PTSD and addiction even when

the original hypothesis would show separation. There is a high correlation between addicts who

may put themselves into dangerous situations, therefore, encouraging traumatic behavior, using

the substance to self-medicate and relive or numb the trauma, or just being emotionally stunted

from the trauma. With all the studies above the most significant implication that was reported

was for practical use for doctors to evaluate both addicts and trauma patients for the often related

disorders. While they acknowledge that not every patient will have both disorders, there are

reported highs of 43% (Saunders et al., 2015; Young-Wolff et al., 2014). With that level of co-

occurrence (not causation), there is enough documentation for practical applications with

preventative questionnaires in both medical fields.

WHAT IS THE RELATIONSHIP BETWEEN PTSD AND ADDICTION? 14

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