What My Experience Working With Veterans can Teach us about Trauma, PTSD

One of the most common stories I hear from the Veterans I work with as part of my Addiction Psychiatry Fellowship is that their addictions spiraled out of control after a traumatic experience or a series of traumas. Whether they experienced trauma in basic training, during a deployment, in combat or after returning home, many Vets can point to specific events that they have not recovered from. Sometimes drugs and alcohol use begins during active duty and in other cases it starts or worsens when they get home. The common thread seems to be that drugs and alcohol, at least in part, are used to self-medicate or to numb the emotional and physical effects of trauma.

In the aftermath of Lamar Odom’s widely reported overdose and hospitalization this past week, he has been a common topic of conversation among both the Vets I treat and among my colleagues. On the surface, veterans at a Veterans Administration (VA) Hospital would seemingly have little in common with Lamar Odom.

However, one of the most commonly reported facets of his life is his long history of loss, trauma and rumors of drug abuse. It is well documented that he lost his mother at age 12; his father suffered from heroin addiction and abandoned the family when Odom was young; he lost his grandmother who raised him at age 23; he lost a child to sudden infant death syndrome; the day after attending a funeral he planned for his younger cousin (who was shot to death), he was a passenger in an SUV that hit a motorcycle which then struck and killed a pedestrian (who Odom witnessed dying); and he lost two close friends this past summer from drug addiction. The Los Angeles times quoted a trauma survivor as saying “I think the effects of seeing [my cousin] die and then watching this kid die, it beat me down...I thought I was breaking down mentally.” This quote was from Odom but could just as easily been from a Vet at the VA.

Lamar Odom posing with his friends, two of which died from complications of substance abuse this summer.
Photo credit: http://www.people.com/article/bobby-heyward-dies

We know Odom was a survivor of repeated trauma, yet whether or not he developed PTSD or suffers from addiction would only be speculation. However, being a trauma survivor, especially as a youth, raises his risk of developing both disorders. One hypothesis as to why trauma survivors develop addictions is to deal with the symptoms of post traumatic stress disorder (PTSD). This stems from 1999 study that found that endorphin levels increase substantially during a traumatic experience. However, after the trauma there is a period of decreased endorphins that is thought to contribute to anxiety, irritability, depression and other signs of PTSD. Substances of abuse, such as alcohol, increase endorphin levels and therefore may be used to self-medicate the symptoms of PTSD.

The VA has noted the association between PTSD and substance use disorders and has published some statistics. They have published data showing that about 20% of Vets with PTSD also have a substance use disorder. Conversely, they have found that about 1/3 of Vets with substance use disorders also have PTSD. Vets with PTSD smoke at almost twice the rate as Vets without PTSD. Lastly, about 10% of Iraq and Afghanistan Vets have a problem with either drugs or alcohol.

It is very common for Vets to have both PTSD and Substance Use Disorders
Image Credit: http://www.psychiatrictimes.com/military-mental-health/returning-veterans-addictions

Those who suffer from PTSD may self-medicate for differing reasons. An article from the VA notes that some may drink or use drugs to help them sleep. Others may take substances to “numb” the pain, which can be emotional (anger/depression/ irritability/guilt) or physical. The problem they note is that drugs and alcohol continue a cycle of avoidance and can make PTSD last longer. While the substances help for a short time, in the long run they prevent treatment of the factors that will lead to a happier and healthier life in the long-term.

The hardest part, especially for Vets, is to admit you have a problem and you need help. Many times I have found that those who are used to being the “rock” or the person their friends and family turn to for help have the most trouble asking for help themselves. Reaching out for help can be refreshing because you do not have to suffer alone. Whether you are a Vet, a celebrity, or a regular citizen with PTSD and/or substance abuse, there are many evidence-based treatments that can help. There are individual or group therapies such as cognitive behavioral therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR), or medications that help manage the symptoms of both PTSD and substance use disorders. The VA has made it very easy to find both PTSD and Substance abuse treatment programs for Vets.

The statistics about Military PTSD, suicide and trauma is troubling and under-reported.
Image Credit: American Psychiatry Association, Psychiatry.org

Another common theme I see among Vets and civilians with substance use disorders is shame. Dr. Garrett O’Connor, who recently passed, spoke and wrote extensively on malignant shame in addicts. The shame affects both the substance abusers, who often act and think in ways they regret when using, and their families, who suffer the consequences of the addiction as well. He points out that shame is different than guilt, noting guilt is about action and behavior, while shame is about identity and self. Dr. O’Connor felt that malignant shame is the core feeling or effect of addiction. While it is often expressed as rage, fear, anxiety or despair, he felt that malignant shame pierces our ego and wounds our soul. He conversely noted that when an addict hits “rock bottom” healthy shame motivates them not to drink or use drugs. In this way he felt that shame can either be paired with despair and lead to morbidity and mortality or it can be pair with hope and lead to recovery and sobriety.

Dr. O'Connor is one of the fathers of the field of Addiction Medicine and more about him and his life's work can be found here andhere

It is easy to see how someone suffering from PTSD and addiction could feel malignant shame and be adverse to reach out for help. Shame can make us feel unworthy of help and unlovable. This may also be why so many loved ones of addicts feel so helpless and alone in their struggle to help as shame is very isolating. Could PTSD and substance abuse or addiction help to explain Lamar Odom’s apparent freefall and recent overdose and hospitalization? Maybe. I would not want to speculate because he is not my patient. However, if he was, and I was working with him and his family, I would encourage them to engage in the treatment and get a thorough assessment to rule out PTSD and substance use disorders among others. If he does suffer from addiction or alcoholism, as discussed above, the key is to turn malignant shame into healthy shame, as Dr. O’Connor noted is essential for recovery.

Stay Tuned!

Dr. Goldenberg

Twitter: @docgoldenberg

The Huffington Post: http://www.huffingtonpost.com/dr-matt-goldenberg-do-/
Matthew Goldenberg, D.O. Matthew Goldenberg D.O. is double Board Certified in Psychiatry and Addiction Psychiatry and is a certified Medical Review Officer (MRO). He is an expert in the evaluation and treatment of mental health disorders and is an addiction specialist for adults in his private practice in Santa Monica, California. Dr. Goldenberg also provides addiction psychiatry consultations to some of the nation’s top residential and outpatient treatment programs in the Los Angeles area and is experienced in the evaluation and treatment of professionals working in safety-sensitive positions. In addition to his clinical work, Dr. Goldenberg is an active author, researcher and invited speaker at local and national conferences. He also volunteers his time as a Clinical Instructor in the Department of Psychiatry at UCLA and is an Assistant Professor of Psychiatry at Cedars Sinai Medical Center.

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