PTSD and addiction: Why they occur together and how to treat both

Post-traumatic stress disorder (PTSD) and addiction frequently occur together. Many people with PTSD use alcohol or drugs to blunt flashbacks and nightmares, or the constant sense of threat that follows trauma. Substance use then makes PTSD symptoms harder to escape.

Many South African adults have lost someone close without warning or witnessed trauma happening to others. The overlap between PTSD and addiction affects many families as a result. Treating both conditions at the same time gives people the best chance of recovering from each.

This article focuses on diagnosed PTSD and its relationship with substance use. The article covers how PTSD develops, why it so often leads to alcohol or drug problems, and what research shows about treating both.

Our article on trauma and addiction covers the broader link between traumatic experiences and addiction, including childhood adversity.

What is PTSD?

PTSD is a mental health condition that can develop after someone experiences or witnesses a traumatic event. Examples include violence, a serious accident, sexual assault, and the sudden death of a loved one. Most people who go through trauma don’t develop PTSD. For some, though, symptoms persist for months or years and interfere with daily life.

PTSD symptoms fall into four groups:

• Re-experiencing: Flashbacks, intrusive memories, and nightmares about the event
• Avoidance: Steering clear of people, places, or feelings that bring back the trauma
• Negative changes in thinking and mood: Guilt, shame, numbness, and detachment from others
• Heightened arousal: Jumpiness, irritability, poor sleep, and feeling constantly on guard

Alcohol and drugs temporarily relieve many of these symptoms. That short-term relief goes a long way to explaining why the two conditions so often occur together.

PTSD in South Africa

The South African Stress and Health study surveyed a nationally representative sample of South African adults. The most common traumatic events were the unexpected death of a loved one and witnessing trauma happening to someone else.

The study estimated that 2.3% of South African adults will develop PTSD at some point. Among people exposed to trauma, 3.5% went on to develop it. Witnessing trauma carried the highest risk of PTSD, and of PTSD becoming chronic. The researchers suggested that the public setting of much trauma in South Africa may explain why witnessing plays such a large role here.

PTSD estimates vary between countries. A large national survey in the United States put lifetime PTSD at 6.4%. The survey linked PTSD with higher rates of substance use disorders, as well as mood and anxiety disorders.

Why PTSD and addiction occur together

PTSD and substance use reinforce each other, and the pattern often becomes self-sustaining.

Using substances to cope with symptoms

Alcohol, cannabis, and sedatives can dull intrusive memories and take the edge off hyperarousal. They can also make it easier to fall asleep. For someone who dreads nightmares, a drink or a pill at night can feel like the only way through. Over time, the person needs more of the substance for the same effect, and dependence develops.

How substances keep PTSD going

Substance use also interferes with recovery from trauma:

• Withdrawal causes anxiety, poor sleep, and irritability, which overlap with PTSD symptoms and intensify them
• Intoxication raises the risk of further traumatic experiences, such as accidents and assaults

Why stopping can feel worse at first

For some people with PTSD, the symptoms that alcohol or drugs were masking return in full once they stop. Flashbacks, nightmares, and anxiety can feel more intense in early sobriety, and that pressure can trigger relapse. Planning for this period, with trauma-focused support in place, makes it more manageable.

Treatment for PTSD and addiction

PTSD and addiction respond best to treatment that addresses both together. Treating only the addiction leaves the symptoms that drive substance use untouched. Trauma therapy, in turn, is harder to engage with while substance use continues.

Detox and safety first

Treatment usually starts with stopping substance use safely, in a stable and predictable environment. At Houghton House, patients spend their first three days in our medical detox unit. They see a doctor daily and receive round-the-clock nursing care. Feeling physically safe provides a foundation for later trauma work.

Trauma-focused therapy

Clinicians once worried that working directly on traumatic memories might trigger relapse in people with addiction. The evidence suggests otherwise.

• A randomised controlled trial: The  trial, published in JAMA, tested an integrated, exposure-based therapy for people with PTSD and substance dependence. Participants who received the therapy alongside usual addiction treatment saw a greater reduction in PTSD symptoms. Their substance dependence didn’t worsen.
• A Cochrane review: The review of psychological therapies for people with both conditions found that individual trauma-focused therapy reduced PTSD severity more than usual care. The therapy was delivered alongside substance use treatment, and benefits lasted several months. The review rated the evidence as low quality and noted that fewer people completed trauma-focused therapy.

The 2023 guideline from the United States Veterans Affairs and Department of Defense recommends specific trauma-focused psychotherapies ahead of medication. These include prolonged exposure, cognitive processing therapy, and eye movement desensitisation and reprocessing (EMDR).

Therapy at Houghton House

Houghton House’s rehab programme runs for 30 days, extendable to 42 when clinically necessary. Treatment includes:

• Trauma and grief therapy
• Cognitive behavioural therapy (CBT)
• Dialectical behaviour therapy (DBT), which teaches skills for managing overwhelming emotions without turning to substances
• Mindfulness, and individual and group counselling

Our article on trauma and addiction describes our trauma-informed approach in more detail.

Psychiatric care and medication

Houghton House is licensed as both a rehabilitation centre and a private psychiatric hospital. An in-house psychiatrist assesses every patient on admission and can prescribe medication where needed.

The VA/DoD guideline recommends three antidepressants for PTSD: Paroxetine, sertraline, and venlafaxine. The guideline recommends against benzodiazepines and against cannabis in any form. That advice carries extra weight for people whose substance use already involves sedatives or cannabis.

Aftercare

PTSD symptoms and cravings can both flare up after discharge, particularly around anniversaries or reminders of the trauma. Our aftercare programme continues therapy and peer support. The team also helps people build a plan for those moments.

How families can help

Living with someone who has PTSD and an addiction can be frightening and confusing. Their reactions may seem out of proportion, and they may withdraw from the people closest to them. A few steps help:

• Learn about PTSD, which can help you see irritability or anger as symptoms rather than personal rejection
• Avoid pressuring the person to talk about the trauma before they’re ready
• Encourage treatment that addresses both PTSD and substance use
• Get support for yourself, especially if the same event affected you

Our family support programme runs weekly meetings for anyone affected by a loved one’s addiction.

If someone is in crisis or talking about suicide, act immediately. Contact emergency services, or call the South African Depression and Anxiety Group (SADAG) suicide crisis helpline on 0800 567 567.

Medical aid cover for PTSD and addiction treatment

Substance use disorders are prescribed minimum benefits (PMBs) in South Africa. All registered medical aids must therefore cover addiction treatment. Houghton House is also a licensed psychiatric hospital. Patients can claim for additional mental health services where a co-occurring condition qualifies under psychiatric PMBs.

Our admissions team checks your benefits and handles pre-authorisation for you. Visit our medical aid cover page, or contact our admissions team to find out what your scheme covers.

Frequently asked questions about PTSD and addiction

Can PTSD cause addiction?

PTSD significantly raises the risk of developing a substance use disorder. Many people use alcohol or drugs to manage symptoms such as nightmares and flashbacks. Not everyone with PTSD develops an addiction. Even so, anyone with PTSD who drinks or uses drugs regularly should mention it to their doctor.

Is it safe to do trauma therapy while recovering from addiction?

For most people, yes. In a randomised trial, an integrated exposure-based therapy reduced PTSD symptoms without worsening substance use. A Cochrane review found similar benefits for trauma-focused therapy delivered alongside addiction treatment.

What is the difference between trauma and PTSD?

Trauma refers to an overwhelming experience and its effects. PTSD is a specific, diagnosable condition with a defined set of symptoms that persist after a traumatic event. Many people experience trauma without developing PTSD. Our article on trauma and addiction explains the broader relationship.

Where can I get help for PTSD and addiction in South Africa?

Houghton House in Johannesburg treats addiction alongside co-occurring mental health conditions, including PTSD. Call our admissions team on [011 787 9142](tel:+27117879142) for a free, no-obligation telephonic evaluation, or contact us online.

Sources

• Atwoli, L., Stein, D. J., Williams, D. R., McLaughlin, K. A., Petukhova, M., Kessler, R. C., & Koenen, K. C. (2013). Trauma and posttraumatic stress disorder in South Africa: Analysis from the South African Stress and Health Study. BMC Psychiatry, 13, Article 182. https://doi.org/10.1186/1471-244x-13-182 
• Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., Sannibale, C., Barrett, E. L., Merz, S., Rosenfeld, J., & Ewer, P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA, 308(7), 690–699. https://doi.org/10.1001/jama.2012.9071 
• Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25(3), 456–465. https://doi.org/10.1016/j.janxdis.2010.11.010 
• Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2016). Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database of Systematic Reviews, 2016(4), Article CD010204. https://doi.org/10.1002/14651858.CD010204.pub2 
• Schnurr, P. P., Hamblen, J. L., Wolf, J., Coller, R., Collie, C., Fuller, M. A., Holtzheimer, P. E., Kelly, U., Lang, A. J., McGraw, K., Morganstein, J. C., Norman, S. B., Papke, K., Petrakis, I., Riggs, D., Sall, J. A., Shiner, B., Wiechers, I., & Kelber, M. S. (2024). The management of posttraumatic stress disorder and acute stress disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Annals of Internal Medicine, 177(3), 363–374. https://doi.org/10.7326/M23-2757