It is one of the most common patterns in clinical mental health work: a person with a significant trauma history also struggles with alcohol misuse, prescription medications, or other substances. For years, these were treated as separate problems. The research now tells a more complicated and more compassionate story.
The connection between trauma, post-traumatic stress disorder, and substance misuse is well-established. Most published studies support a pathway in which PTSD precedes substance misuse, meaning trauma comes first, and substance misuse often follow as a response to it (Breslau, Davis, Peterson, & Schultz, 1997; Chilcoat & Breslau, 1998; Jacobsen, Southwick, & Kosten, 2001). This is not a coincidence or a character failure. It is, in many cases, an attempt to manage unbearable internal experience.
One of the most clinically significant explanations for this pattern involves dissociation. Research has suggested that trauma survivors may use substances specifically to achieve dissociative states, to create distance from traumatic cues to quiet intrusive memories, or to numb the hyperarousal that keeps the nervous system in a constant state of threat (Langeland, Draijer, & van den Brink, 2002). In other words, the substance is doing what the mind cannot do on its own: creating relief from the experience of being inside one’s own body.
Good (1989) demonstrated that a wide range of psychoactive substances, including alcohol, can induce dissociative experiences including depersonalization, amnesia, and impairments in the sense of self. For someone whose nervous system is chronically overwhelmed, this chemically induced disconnection may be the only respite they have found.
This creates a deeply problematic cycle. Trauma produces dissociation. Dissociation is painful and disruptive. Substances temporarily reduce or create a more manageable version of it. But over time, substance misuse maintains and deepens the neurological and psychological dysregulation underlying both the PTSD and the dissociative symptoms. The short-term relief makes the long-term problem worse.
Langeland and colleagues (2002) found an additional layer of complexity in their study of treatment-seeking alcoholics: those with a history of lifetime medication use showed higher severity of dissociative symptoms, suggesting that substances may actually mask the extent of dissociation when it is clinically assessed. This has real implications for treatment. A person presenting for substance use treatment may appear to have mild trauma symptoms not because their trauma is mild, but because the substances have been suppressing the full clinical picture.
What does this mean for treatment? It means that addressing substance use without addressing the underlying trauma, and specifically the dissociative symptoms that may be driving substance use, is unlikely to produce lasting recovery. It also means that evaluating trauma and dissociation should be a standard part of intake for anyone presenting with substance use concerns.
This is not about adding complexity to treatment. It is about treating the whole person. At Let’s Talk Psychological Wellness, we understand that what looks like one problem is often two problems that cannot be separated, and that healing requires attending to both. We bring decades of experience in the assessment of these conditions.
If you or someone you know is struggling with both trauma and substance use, know that integrated, evidence-based treatment exists. Reaching out is the first and most important step.
References
Breslau, N., Davis, G. C., Peterson, E. L., & Schultz, L. R. (1997). Psychiatric sequelae of posttraumatic stress disorder in women. Archives of General Psychiatry, 54(1), 81–87.
Chilcoat, H. D., & Breslau, N. (1998). Investigations of causal pathways between PTSD and drug use disorders. Addictive Behaviors, 23(6), 827–840.
Good, M. I. (1989). Substance-induced dissociative disorders and psychiatric nosology. Journal of Clinical Psychopharmacology, 9(2), 88–93.
Jacobsen, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158(8), 1184–1190.
Langeland, W., Draijer, N., & van den Brink, W. (2002). Trauma and dissociation in treatment-seeking alcoholics. Journal of Traumatic Stress, 15(5), 369–376.
Caldeira, N. A. (2004). Dissociation and Treatment Outcome in Urban Women with Comorbid PTSD and Substance Use Disorders. ProQuest, April 2004. UMI Dissertation Services Microform 3126239.