Dr. Koola is Associate Professor, Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, DC.
Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Often, clinicians tend to focus on the diagnosis and treatment of psychiatric disorders, such as psychosis, bipolar disorder, depression, anxiety, insomnia, and substance use disorders (SUD), but posttraumatic stress disorder (PTSD) often is overlooked and underdiagnosed,1 especially when comorbid with another psychiatric disorder such as SUD.
The primary symptoms of PTSD are recurrent and include intrusive memories and dreams of the traumatic events, flashbacks, hypervigilance, irritability, sleep disturbances, and persistent avoidance of stimuli associated with the traumatic event. According to the National Comorbidity Survey, the estimated lifetime prevalence of PTSD among adults is 6.8% and is more common in women (9.7%) than men (3.6%).2 Among veterans, the prevalence of PTSD has been reported as:
31% among male Vietnam veterans (lifetime)
10% among Gulf War veterans
14% among Iraq and Afghanistan veterans.3
Why is PTSD overlooked in substance use?
Among individuals with SUD, 10% to 63% have comorbid PTSD.4 A recent report underscores the complexity and challenges of SUD–PTSD comorbidity.5 Most PTSD patients with comorbid SUD receive treatment only for SUD and the PTSD symptoms often are unaddressed.5 Those suffering from PTSD often abuse alcohol because they might consider it to be a coping strategy. Alcohol reduces hyperactivation of the dorsal anterior cingulate cortex caused by re-experiencing PTSD symptoms. Other substances of abuse, such as Cannabis, could suppress PTSD symptoms through alternate mechanisms (eg, endocannabinoid receptors). All of these could mask PTSD symptoms, which can delay diagnosis and treatment.
SUD is the tip of the “SUD-PTSD iceberg.” Some clinicians tend to focus on detoxification while completely ignoring the underlying psychopathology of SUD, which may be PTSD. Even during detoxification, PTSD should be aggressively treated.6 Lastly, practice guidelines for managing SUD–PTSD comorbidity are lacking.
