Current research demonstrates that a person with a history of trauma has a greater likelihood of struggling with substance abuse and addiction. The studies show the importance of addressing trauma as part of the treatment plan for those experiencing addiction. But too often, trauma-related symptoms are mislabelled or undiagnosed by clinicians. And clients who have a trauma history often minimize or downplay their painful life experiences.
There are significant adverse outcomes for those dealing with addiction who have a history of traumatic experiences. Unidentified and unresolved trauma makes engagement in addiction treatment more difficult. Trauma symptoms can reduce the ability to benefit fully from addiction treatment. It also makes the risk of relapse even higher. Understanding the connection between trauma and addiction is vital to the process of healing and recovery for everyone who has been impacted by both.
The research clearly identifies trauma as a substantial contributing factor to patterns of substance dependence. Studies indicate that traumatic experiences, especially when they occur early in life, create a greater vulnerability to developing substance abuse problems. These statistics highlight this strong connection:
In North America, the percentage of people diagnosed with PTSD over the course of their lifetime is about 7%. In the substance abusing population, this percentage increases dramatically – studies show that 36-50% of people receiving treatment for substance abuse also experience the symptoms of PTSD.1
Dr. Edward Khantzian, the Harvard Medical School professor who developed the self-medication hypothesis of substance abuse, states that people with PTSD are four times more likely to develop problems with substance abuse than those without. A history of PTSD and trauma also leads to people starting their substance use at an earlier age as well as greater severity of use.2
The National Comorbidity Study looks at how often one condition or illness occurs alongside another one. This study shows that as many as 46% of people with either PTSD or a substance abuse disorder also have the other condition. The study also indicates that that trauma is more likely to occur before drug or alcohol abuse rather than after it occurs.3
Updating the Definition of Trauma
As our knowledge of neurobiology and the human nervous system has expanded, we have gained increased awareness about the impacts trauma makes on our nervous system. We have come to see how common traumatic experiences are as well the significant impact they have on physical and mental health as well as overall functioning. Besides the sources of trauma that are universally acknowledged such as assaults or abuse, there are many other additional sources of trauma that can lead to negative impacts. Some of these experiences include medical procedures, falls and concussions, natural disasters, and relational traumas as well as growing up in a family where there was a parental addiction, mental health issues, high levels of conflict, or unresolved parental trauma.
The Connection Between Trauma and Addiction
Some of the recent advances in addiction treatment have come from an increased awareness and understanding of trauma, trauma-related symptoms and how they impact the move into substance abuse. Vincent Felitti and Robert Anda have completed groundbreaking research about the consequences of childhood trauma in the Adverse Childhood Experiences Study (ACE Study). This study clearly illustrates the impacts of a wide variety of traumatic experiences are cumulative and lead to significant adverse outcomes, including health issues and substance abuse.4
The ACE Study demonstrates that substance abuse, as well as other compulsive behaviours, can become a way of managing the overwhelming experiences of childhood trauma and adverse experiences. Substance abuse often begins as a way of coping with symptoms related to trauma. It can be a way to stop intrusive memories, self-soothe, manage anxiety, shame, or anger as well as offering ways to numb or dissociate.
Two Basic Categories of Trauma Symptoms
The symptoms of trauma can be simplified if we view them as falling into two basic types. Trauma researchers often classify symptoms as being “bimodal” – having two distinct ways these symptoms are experienced. One category is referred to as “hyper-arousal” and is related to the increased activation of the fight or flight response following trauma or stress. The other category is referred to as “hypo-arousal” – it is more related to the freeze response of trauma and includes such experiences as numbing and dissociation.5
1. Hyper-arousal: High Activation, Intrusive Experiences, and Fear
The term “hyper-arousal” is used to describe the high level of activation that remains in the nervous system and the physical body following a traumatic experience. It is essentially an ongoing activation of the fight or flight response even after the threat or the trauma has ended. Some people continue to live in this state of high trauma activation, and it alters their experience of themselves and the world around them. When this high activation of the nervous system remains following a trauma, it contributes to the development of trauma symptoms that fall into the hyper-arousal category. This category of symptoms include:
The Nervous System is on High Alert: A person may be jumpier or startle easily, more reactive, more impulsive as well as experience greater irritability or even aggressiveness. Hyper-vigilance becomes a way of being in the world – they are always watchful for any sign of potential threat. Sleep becomes difficult.6 When nervous system activation is high, it makes both sleep and learning difficult.
Physical Symptoms: When the nervous system remains on “high alert” the body also remains on high alert. A person can experience overwhelming bodily sensations following trauma if the physical manifestations of the fight or flight response continue after the danger has passed.5 Some of the physical symptoms include tension and stomach upset as well as all the physical manifestations of a fear response.
Re-experiencing Symptoms: These are the profoundly disturbing experiences that include trauma-based flashbacks, nightmares, and intrusive images. Intrusive experiences are ways that a person continues to relive their original trauma.
Emotional Reactivity: The ongoing emotional experience following trauma can be one of reliving the primary emotions of trauma including heightened anxiety, fear, horror, shame, and anger. There can also be a greater struggle with expressing anger in appropriate ways.
Self-Destructive Behaviors: Trauma also leads to self-destructive behaviours that are often attempts to manage the overwhelming experience of high activation – self-harm, disordered eating, compulsive sexual activity, and substance abuse become common experiences.5
2. Hypo-arousal: Avoidance, Numbing, Disconnection and Dissociation
The term “hypo-arousal” is used to describe another (and different) nervous system state that results from the high level of activation that remains in the nervous system and the physical body following a traumatic experience. Rather than a state of high activation experienced through the symptoms of hyper-arousal as listed previously, the hypo-arousal symptoms show up as a state of dissociation or disconnection that results when trauma and traumatic stress become overwhelming, and the nervous system moves into a “freeze” response.
Peter Levine acknowledges that dissociation helps make the unbearable bearable.7 He describes this freeze response as being similar to both the accelerator and the brake being applied at the same time creating a forceful turbulence inside the body that produces the “hypo-arousal” symptoms of traumatic stress.7 It is as if the wheels are spinning but the car isn’t going anywhere. This type of response occurs without conscious thought – it is an instinctive response to an overwhelming experience. And it occurs, in part, as a way of buffering against the painful experiences of trauma symptoms.
When this high level of trauma activation in the nervous system results in a “freeze” response, it contributes to the development of trauma symptoms that fall into the hypo-arousal category. This category of symptoms include:
Physical, Emotional, and Relational Experiences: There is a sense of being emotionally numb, detached, or empty. A person can feel out of touch with their emotions and their body. There may be challenges with being forgetful or “spaced out”. Traumatic experiences can also create a tendency to withdraw and isolate. There can be an avoidance of intimacy or connection with other people.
Behavioral Symptoms: Those who learned to cope with trauma by dissociating or shutting down often continue to respond in similar ways when they face stress.5 Hypo-arousal and dissociation are also significant contributors to substance abuse and addiction – to counter a pervasive experience of numbness and detachment, there can be a move towards high-risk behaviours or sensation-seeking in dramatic ways including high-risk substance abuse and behavioral addictions such as sexual acting out and excessive gambling.
Substance Abuse and the Symptoms of Trauma
Substance abuse and compulsive behaviors are common among those who have been through traumatic experiences and who continue to suffer from ongoing trauma symptoms. For those who experience a constant sense of reliving their trauma and living in a state of hyper-arousal and the high activation of a chronic fight or flight response, it is no wonder they might seek out options to help them shut down or numb out.5 For others, they use substances as a way of countering the numbness and detachment they experience in the hypo-arousal state. There is also research that defines substance abuse as an attempt to bring a sort of “chemical dissociation”.
Willie Langeland and his colleagues were some of the first researchers to study the concept of chemical dissociation. Their research points out that some substance abusers may have more limited ability to dissociate in the truest clinical sense – so they likely rely on substances to produce a dissociative state. “Traumatized individuals with limited capacities to psychologically dissociate may attempt to produce similar soothing or numbing effects by using psychoactive substances. These substances are used to enter and maintain dissociative-like states.”8 Although dissociative states tend to “feel better” than the state of high activation and hyper-arousal, they are certainly not healthier as they only bring further damage and disconnection that results from an ongoing disconnection from healthier resources, coping tools, and relationships.
We need to understand that addiction is often a symptom of the problem rather than the problem itself. For many people who struggle with addiction, substance abuse begins as an attempt to fix a problem that was created through trauma. Substance abuse is often a person’s way of managing a “problem” rather than being the only issue that needs addressing. If we fail to take into consideration this crucial fact, we set people up for a struggle in their recovery. By shifting our perspective in this way, we help create more compassion and more support for those wanting to make lasting and positive change in their patterns of substance abuse and addiction.
1 Weiss, N., M. Tull, M. Anestis, and K. Gratz. “The Relative and Unique Contributions of Emotion Dysregulation and Impulsivity to Posttraumatic Stress Disorder among Substance Dependent Inpatients.” Drug and Alcohol Dependence 128.1-2 (2013)
2 Khantzian, E. J. “The Self-Medication Hypothesis Revisited: The Dually Diagnosed Patient.” Primary Psychiatry Archive (2003). Primary Psychiatry. 2003.
3 Coffey, S. F., J. P. Read, M. M. Norberg, S. H. Stewart, and P. Conrod. “Posttraumatic Stress Disorder and Substance Use Disorder: Neuroimaging, Neuroendocrine, and Psychophysiological Findings.” Anxiety and Substance Use Disorders the Vicious Cycle of Comorbidity. 2008.
4 Felitti, V., R. Anda, R. Lanius, E. Vermetten, and C Pain. “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Health Care.” The Impact of Early Life Trauma on Health and Disease the Hidden Epidemic. 2010.
5 Van Der Kolk, B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. 2014.
6 Luxenburg, T., J. Spinazolla, and B. A. Van Der Kolk. “Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Assessment: Part One.” Directions in Psychiatry 21 (2001): 373-92. Trauma Center at JRI. 2001.
7 Levine, P. A. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. 2010.
8 Langeland, W., N. Draijer, and W. Van Den Brink. “Trauma and Dissociation in Treatment-seeking Alcoholics: Towards a Resolution of Inconsistent Findings.” Comprehensive Psychiatry 43.3. 2002.