What you need to know about the relationship between PTSD, trauma, and substance abuse

Posttraumatic stress disorder (PTSD) and addiction are two very different challenges that are sometimes experienced at the same time. People are often curious about the ways that these two struggles overlap.  There are actually several ways that PTSD and substance use go together.

Substances as a solution

People who have PTSD struggle with anxiety and fear, isolation, and sleep difficulties.  Substance use can, understandably, seem like a solution.

Using alcohol might help someone who feels on guard all the time to be able to relax.  Benzodiazepines or marijuana might be used to help individuals who suffer from trauma to fall asleep.  People with PTSD may use substances to avoid thoughts, feelings, or memories associated with the traumatic event.

Research suggests that the relief from substances is short-lived and does not permanently improve the experience of individuals with PTSD, even if it does provide some temporary aid.  In fact the reality is quite the opposite – avoiding symptoms actually helps to maintain the symptoms of PTSD in the long run. The more that trauma-related thoughts and feelings are avoided, the worse symptoms become.

PTSD often leads to negative views of other people or the world, and as a result people with PTSD sometimes feel quite disconnected from friends and family. Using alcohol or other substances may seem like a good way to temporarily suspend those negative beliefs and connect with others.  Again, although using substances may temporarily help someone feel the connection to others that they’re craving, this is not a permanent solution and there are often unintended side effects that wreak havoc in their lives.

Substance abuse sometimes causes trauma

Substance use can, unfortunately, lead to further trauma.

Substances themselves can have effects that can be traumatic, for example a terrifying acid trip or an accidental overdose.  In a similar way, when people are under the influence of substances, their inhibitions are lower and so they are more likely to get into situations where traumatic events occur.  It’s common for people who are under the influence of substances not to feel the full impact of the trauma until later.

It’s important to note that it is less common for substance abuse to lead to trauma; much more often individuals have traumatic experiences and then begin using substances as a way to cope.   They may then be more susceptible to those additional traumatic experiences for a number of reasons, including environmental factors and reduced inhibition when under the influence.

Treatment solutions for both PTSD and substance abuse

When considering the co-occurrence of PTSD and substance abuse, it makes a lot of sense that these disorders go together.  Substance use promises quick relief from pain, and the pain of trauma can sometimes seem intolerable.  However, using substances rarely provides any kind of long term relief and can have a number of negative consequences.

The good news is that a number of effective treatments for co-occurring PTSD and substance abuse have been developed and there are specialists who are trained to help.  Treatment with a qualified professional is a critical part of healing and creating the life that those who suffer from trauma and substance abuse desire and deserve.

If you or someone you love is currently struggling, contact our office today to schedule an initial assessment.

Serving Those Who Have Served: Caring for veterans and their companion animals

“Thank you for your service!” How many of us have offered these words of appreciation when we see a service member in uniform? And they are appropriate, albeit vastly insufficient words. But as I was perusing Upworthy on Veteran’s Day morning, I came across stories of two amazing organizations that are expressing their appreciation to our veterans in a much more profound and tangible way. While there are many groups out there doing fantastic work serving veterans, these two groups, PACT for Animals and Pets for Vets, are doing so in a somewhat different way.

PACT for Animals is a non-profit that provides temporary foster homes for the pets of military services members when they are called for deployment. They also foster pets of those who are hospitalized and are temporarily unable to care for their pets. By fostering these animals, they not only offer piece of mind for those serving our country that their companion animal won’t end up in a shelter and that they will be well loved until they can be reunited, but the foster families also provide regular updates to pet owners, including photos, messages and videos of their beloved pets. Check out this Upworthy video to see the amazing work this group is doing. Given the incredible sacrifices our veterans have made to serve our country, it seems to me that doing what we can to make sure their loved ones, including their four-legged loved ones, are taken care of while they are deployed is the least we can do.

Pets for Vets is dedicated to supporting veterans and providing a second chance for shelter pets by rescuing, training and pairing them with veterans who could benefit from a companion animal. The group takes animals from shelters that would otherwise be euthanized and then professional animal trainers rehabilitate the animals and teach them good manners to fit into the veteran’s lifestyle, whether that be desensitizing them to wheel chairs, being of assistance to someone with a TBI, or being an emotional assistance animal to someone struggling with PTSD. Check out this Upworthy video on the project.

Although research in this area is still somewhat preliminary (and antecdotal opinion seems to have gotten ahead of the data), there is growing evidence of the physical and mental health benefits companion animals can provide. Groups like PACT for Animals and Pets for Vets are harnessing the healing power of pets as a way to serve those who have served our country. On this Veteran’s Day I wanted to take a moment to express my appreciation not only to those who have served, but also those who support those who have served in all the various ways we do that, from my incredibly dedicated colleagues who work at VAs to groups like PACT for Animals and Pets for Vets. Thank you ALL for serving in the way that you do.

Psychotherapy Changes the Brain, Too: A Look at PTSD Treatment

It has become fashionable nowadays in psychotherapy circles to talk about neuroscience and interventions that target the brain. Some writers refer to this bias as “neurocentrism,” the notion that our behavior is best explained by locating it in the brain.

There’s a treatment for posttraumatic stress disorder (PTSD) called Eye Movement Desensitization and Reprocessing (EMDR) that anticipated this trend 20 years ago by using gimmicky neurological language as window dressing to sell the idea that it uniquely effects the brain. This marketing has been really effective, as EMDR has become a well-known “brand name” treatment even though there’s no evidence it’s more effective than other trauma-focused approaches. What people don’t often realize is that psychotherapy has always impacted the brain because making changes in how we think and behave affects the brain.

A new study about post-traumatic stress disorder (PTSD) shows how psychotherapy changes the brain. PTSD consists of a series of struggles (e.g., intrusive thoughts, irritability) that can develop after someone experiences one or more traumatic events. Many people recover after a trauma, but about 10% may develop problems that don’t go away without treatment. In this study, researchers looked at changes in the brain and gene expression before and after cognitive behavioral therapy for PTSD.

The Study

Researchers treated 39 people with PTSD with twelve 90-minute sessions of trauma-focused cognitive behavioral therapy (CBT). Brain scans and blood draws were taken before and after treatment. I found several results really interesting.

CBT Increases Hippocampus Volume

One finding is that there was an actual change in brain matter. The hippocampus is a part of the brain involved in memory. In this study, the size of the hippocampus increased by the end of treatment and these changes were related improvement in PTSD symptoms. The hippocampus can be directly impacted by high levels of long-term stress—such as PTSD—and has been shown to atrophy under these conditions. It appears that psychotherapy can help undo these changes.

The authors note that a prior study did not find any change in hippocampus volume following therapy for PTSD. They note that in the other study, the participants were more severe and had more chronic PTSD; consequently, they speculate that earlier intervention may be extremely important in bringing about improvements.

Changes in Gene Expression

The other biological marker of change the researchers looked at was the FKBP5 gene. Genes are outside my area of expertise, so I’ll try to summarize the results as accurately as I can. Apparently there’s evidence that FKBP5 is associated with anxiety and mood-related problems, and that it can be impacted by stressful external experiences. Reduced expressions of this gene have been linked to PTSD.

There’s also a relationship between FKBP5 and the hippocampus. Expression of FKBP5 can affect secretion of the stress hormone cortisol, which in turn can lead to atrophy in the hippocampus.

Using blood tests, the researchers found that increased expression the FKBP5 gene was also tied to improvement in PTSD.


To summarize, it appears that psychotherapy for PTSD can lead to actual changes in the brain—including increased volume of the hippocampus and changes in gene expression. It also suggests that early treatment for PTSD may be helpful undoing some of the damage.

The point I want to underscore is this: all effective treatments impact brain function.  Whether a treatment is a drug treatment, electroshock, or psychotherapy, they all affect the structure and function of people’s brains. Dressing up a psychotherapy in the language of neuroscience doesn’t make it any more effective or scientific. Any effective treatment changes the brain.

If you want to read the article yourself, click here for a pdf.

The Ecstasy and the Agony: Using MDMA to treat PTSD

My aunt alerted me to a recent New York Times article on the use of MDMA (known as the street drug Ecstasy) to treat posttraumatic stress disorder (PTSD). I’ve written about research on the use of another drug used recreationally, ketamine, in the treatment of depression and bipolar, so I decided to check out the article.

PTSD involves painful and chronic anxiety and fear following a traumatic experience. People with PTSD often feel like they are reliving the experience through nightmares and flashbacks, may have difficulty sleeping, and may feel detached from themselves and those around them. We’re not sure why some people develop PTSD, but the effects can be devastating. Although we have effective treatments for PTSD, not everyone benefits, so exploring additional options is a noble effort.

The NY Times article reports on an ongoing study of the use of MDMA to treatment people with PTSD. The research is spearheaded by a psychiatrist and nurse couple in South Carolina—Michael and Ann Mithoefer. The couple are aided in their research by the Medical University of South Carolina and funded by The Multidisciplinary Association for Psychedelic Studies.

Initial results from a pilot study were published in the Journal of Psychopharmacology in 2010. You can download the full article here. For the purposes of the blog, I decided to write about published data from this study. While I don’t have any philosophical objection to the rigorous study of recreational drugs, I’m also cautious about making too much of limited studies. Drugs must pass through a variety of rigorous studies and careful analyses before they‘re considered safe enough for the public, and it’s rare that any drug becomes the ‘miracle drug’ often hoped for by the public.

The details of the study

The researchers studied 20 people whom they randomly assigned to receive either MDM-assisted psychotherapy, or the same psychotherapy with an inert placebo. Everyone was assessed two months later to determine if improvements were maintained, and those in the placebo condition were later offered the MDMA-assisted therapy.

Why would a party drug help with PTSD?

The gold standard psychotherapy treatment for PTSD is what’s broadly called exposure therapy. Exposure therapy involves contacting and processing painful reminders of the trauma. However, not everyone benefits from exposure therapy: some people refuse treatment, some become too overwhelmed during treatment, and others are too shut down emotionally to effectively engage.

The authors suggest MDMA may help increase an individual’s willingness to engage painful thoughts and feelings, which may in turn help facilitate successful exposure therapy. While this is a reasonable assumption, theoretically, I do question whether taking a psychedelic drug AND participating in exposure therapy would be less threatening for the majority of people than exposure therapy alone. It might be a hard sell to many people.

What did they do?

The Mithoefers served as the therapists in the study. Participants met with the Mithoefers for a few 90-minute informational sessions. The participants then underwent two sessions lasting 8-10 hours each in which they were administered the MDMA (or placebo). Participants stayed overnight in the clinic after the experimental sessions and were monitored for any medical problems.

Two months after the second experimental session, the researchers followed up with each individual. At that time, they could offer a third MDMA session. Between experimental sessions, participants met for 11 90-minute non-MDMA sessions where they could talk about their experiences following the MDMA sessions.

One thing I was a little uncomfortable with was choice of psychotherapy. Although the authors showed they were familiar with gold standard exposure-based treatment such as prolonged exposure therapy by referencing them in their Introduction, they did not actually use an established treatment. Instead, they created a protocol based on the work of psychiatrist Stanislav Grof, MD, an early advocated of using LSD in psychotherapy. Grof is a controversial figure, regarded as a maverick genius by some and a crackpot by others. Although he continues promote his work, it’s never been tested in rigorous studies.

Referencing gold standard treatments in the intro but basing their treatment on Grof’s work strikes me as a bit of a bait-and-switch.

What did they find?

In brief, people who received MDMA and psychotherapy showed much greater improvement than those who received psychotherapy only. Although there were some side effects from the MDMA, they didn’t appear to be serious and long-lasting. Overall, people seemed to benefit from MDMA-assisted therapy without any major problems.

What I liked about the study

Every study is going to have strengths and weakness, but for a small pilot study, it seemed pretty well done. The measures they used were appropriate and thorough. It appeared they took a number of precautions to ensure the safety of those who participated.

In sum, I thought the design was pretty rigorous, the researchers drew reasonable conclusions about their results, and they acknowledged the problems and limitations with the study. I didn’t see anything sneaky or suspect from what I read.

A few concerns…

Here are some weaknesses of the study. Some are pretty normal and expected, and others are more concerning.

Can you really blind people to a placebo when using a psychedelic drug?

As the authors openly acknowledge, 19 of the 20 participants were able to guess whether they received MDMA or the placebo. This is a common problem in medical research when a drug has strong physical effects. What it means, though, is that it makes it harder to tease out the actual effects from people’s expectations.

For example, as people signed on knowing they might receive MDMA, some may have had greater expectations when they realized they probably received the MDMA; conversely, those in the placebo condition may have been disappointed when they realized they probably didn’t get the MDMA.

MDMA-assisted therapy ain’t cheap!

With 31 hours of contact with two therapists, medical monitoring, and overnight stays in a clinic, MDMA-assisted therapy is going to be much more expensive than basic exposure therapy, which typically involves 10-20 sessions with one therapist for 60-120 minutes.

For these reasons, MDMA-assisted therapy will never be a first line treatment if conducted in this fashion. That said, chronic PTSD is very expensive in the long-term (e.g., meds, inability to work, disability). For people who don’t respond to outpatient treatment, MDMA-assisted may be worth the expense if it helps people who don’t benefit from other approaches.

Why didn’t the researchers adapt a therapy with actual research support?

The authors predicted that MDMA may help individuals more effectively respond to exposure therapy for PTSD. Although the treatment protocol they used contains elements of exposure, it wasn’t based on any gold standard treatments for PTSD.

Instead, they used an invalidated protocol based on the work of Stanislav Grof. This makes me squeamish. Grof’s work has some wonky stuff in it. For example, although this wasn’t included in the protocol, Grof has written that psychological problems occur due to “trauma” during the one’s birth! In his Holotropic Breathwork, people are sometimes encouraged to contact “memories” associated with their births—despite the fact that all science suggests we’re incapable of forming these kinds of memories until around age 2.

This doesn’t mean that all Grof’s ideas are bad, but I have some concern in granting legitimacy to his work given some of the more questionable elements of it.

Concluding thoughts

Despite my concerns, I thought this study was reasonably well-designed and fairly transparent. I think the results are strong enough to warrant continued study of MDMA-assisted therapy for PTSD.

However, I think we’re a long way off from seeing it offered as a treatment to the public. And if it does make it that far, it will likely be a last resort for those who don’t respond to other treatments. If it helps people who don’t find relief for their suffering through other means, however, I’m open to it.

Recognizing Posttraumatic Stress Disorder Awareness Month

Unfortunately, mental struggles are often given scant attention in the media. Many people are surprised to learn that others struggle with the same difficulties. Although posttraumatic stress disorder (PTSD) has been getting more media attention lately because of the recent wars in Afghanistan and Iraq, I was pleased to learn that the secretary for Department of Health and Human Services (HHS) released a statement  recognizing Posttraumatic Stress Disorder Awareness Month. She writes:

During PTSD Awareness Month and on PTSD Awareness Day, June 27, 2012, we focus national attention on this debilitating condition and renew our commitment to support research, education, and treatment for those living with PTSD, as well as for their friends and families.

National recognition and focus on this often debilitating yet treatable problem is a wonderful step in helping people access needed services. I encourage you to read Ms. Sebelius’ statement yourself, and to pass it on to others.