How Type of Treatment and Presence of PTSD Affect Employment, Self-Regulation, and Abstinence

Article excerpt

Posttraumatic stress disorder (PTSD) is associated with increased risk for substance use disorders (SUDs; Najavits, Weiss, & Shaw, 1997). Studies have found rates of PTSD and SUD comorbidity as high as 25-59% (Brown, Recupero, & Stout, 1995; Najavits, et al., 1997; Stewart et al., 2000). Read, Brown and Kahler (2004) found that having PTSD and increased psychiatric distress associated with comorbid disorders was associated with poorer substance use outcomes. Additionally, Ritsher et al. (2002) found that dually diagnosed patients were not only less likely to be in remission when compared to an SUD-only group, but that they did have more severe levels of distress. However, other studies suggest that there are no significant differences for treatment outcomes between those with comorbid PTSD and SUD, and SUD-only groups (e.g., Norman, Tate, Anderson, & Brown, 2007).

Several theorists believe that using substances for extended periods of time may be a causal factor in mental health symptomatology, or that it exacerbates existing psychiatric symptoms (e.g. Blume, Schmaling, & Marlatt, 2000; Miller, Eriksen, & Owley, 1994). Alternatively, self-medication theorists assert that individuals use substances as a coping mechanism for negative emotions (Khantzian, 1997). Ouimette et al. (2007) found that patients with PTSD reported that their substance abuse relapse was in response to depression more often than people without PTSD. Meanwhile, Waldrop, Back, Verduin, and Brady (2007) proposed that alcohol may have dampening effects that help regulate the anxiety of patients with PTSD and that cocaine may increase hypervigilance and self-confidence to help individuals with PTSD feel more in control in social situations. There is some evidence for both theoretical points of view. For example, Gil-Rivas, Prause, and Grella (2009) found that individuals with co-occurring disorders reported that they experienced depressive and anxiety symptoms before relapse, which supports the self-medication theory. However, these individuals reported that those symptoms did not diminish, and in fact, were exacerbated after drug use.

Symptoms of PTSD include intense feelings of fear and anxiety, which may lead individuals with this disorder towards avoidance of people, places, or situations that could cause them to re-experience the trauma (American Psychiatric Association, 2000). Individuals with PTSD also experience self-regulation impairments--a reduction in their ability to logically regulate responses to goals, priorities and environmental demands (Tangney, Baumeister, & Boone, 2004). Impairment of self-regulation causes individuals to experience increased emotional distress, periods of dissociation, loss of trust in relationships and meaning in life, and chronic health problems that cannot be medically explained (Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). Cognitive structures responsible for managing emotional responses become impaired for individuals who have been exposed to both extreme stress and who are chronically dependent on substances (Phan, Wager, Taylor, & Liberzon, 2002). Inhibition of cognitive control processes may affect decision making and impulse control that impacts substance abuse or relapse (Matto, 2007). Conversely, people with high self-control show less impulse-related problems, such as alcohol problems. High self-regulation is also associated with better psychological adjustment (Tangney et al., 2004).

Another factor that may increase positive outcomes for those with PTSD and SUDs is employment. People with psychological disorders find work as a meaningful and satisfying way to expand the broader social and economic networks in their lives (Bluestein, 2008). For instance, in one study, veterans who were able to form social bonds were also more likely to be in remission of PTSD. In contrast, veterans' feelings of isolation and weakening social bonds were more likely to predict chronic PTSD (Koenen, Stellman, Stellman, & Sommer, 2003). …