#PTSD and #Alcohol Series (Part 1) – ‘Chicken OR Egg’

PTSD Word Map I’ve been wondering for some time now: is there any connection (significant or otherwise), between the consumption of alcohol, particularly in large quantities, and the overall impact on the symptoms of Post Traumatic Stress Disorder[1] (PTSD)?

I suppose questioning the link, perceived, implied or implicit, should be something of a naturally expected quandary for me. My background of life and work experiences in and around the licensed trade, Emergency Services, Criminal Justice System enforcement, the Military and latterly Recovery and Mentoring in substance misuse, mean it would be strange for me not to examine the issues and questions in what is an increasing problem.

So what, in simple terms, is PTSD? The UK mental Health charity MIND (www.mind.org.uk) offers the following explanation[2]: If you are involved in or witness a traumatic event, it is common to experience upsetting, distressing or confusing feelings afterwards. The feelings of distress may not emerge straight away – you may just feel emotionally numb at first. After a while you may develop emotional and physical reactions, such as feeling easily upset or not being able to sleep. This is understandable, and many people find that these symptoms disappear in a relatively short period of time. But if your problems last for longer than a month, or are very extreme, you may be given a diagnosis of PTSD.

With the nature of the work our military and emergency services personnel carry out, they are clearly more likely than most to experience incidents leading to possible PTSD. Historically, there has also been a heavy social drinking culture attached to all these professions. Whether this culture is born out of a perceived need to relax from their stressful day or simply, driven by macho peer pressure is mostly immaterial.

Over half of men (55%) surveyed by the NHS in 2012 had drunk more than four units (the lower risk guidelines) in the last week. Nearly a third (31%) drunk twice the maximum lower risk guidelines at least once. The definition of ‘binge drinking’ (for men) is consuming eight or more units in a single session. Subsequently, 5% of men in the UK are “at risk” drinkers i.e. someone who drinks more than 50 units per week[3]. I’m sticking with the statistics for men as there are currently higher percentages of men within the professions covered here.

In 2013 more than one in five adults (21%) said that they do not drink alcohol at all. This figure has also been showing a slight increase year on year[4]. Young adults (16-24yrs) were primarily responsible for this change, with the proportion of young adults who reported that they do not drink alcohol at all increasing between 2005 and 2013[5].

What was previously and often dismissed by indulging participants as ‘heavy drinking’ (50+ units per week), was indeed prevalent however statistics suggest this may well finally be changing? We can but hope that this statistic is also proves to be indicative of a similar trend within our military and emergency services.

PTSD is the mental illnesses most associated with military service but there are also a range of other more common mental illnesses which might affect Service and ex-Service personnel. These include depression, feelings of anxiety, panic attacks and substance misuse and interestingly, most commonly alcohol misuse[6].

Combat Stress (www.combatstress.org.uk), the leading Mental Health charity for veterans in the UK, has experienced an increase in the number of referrals for PTSD over recent years[7]. To that end the following questions become ever more relevant.

Could the symptoms of PTSD be wholly or partly dependent upon the quantities of alcohol consumed by a sufferer, prior to or post diagnosis?
Could alcohol actually exacerbate the symptoms being experienced during occurrences of PTSD?
Which factor appeared first; alcohol issues or PTSD?
Should the management[8] and treatment of the two things be addressed as separate issues or in a more holistic manner?
If alcohol isn’t a direct causation factor leading towards the severity of PTSD symptoms, perhaps there could be some indirect correlation between the two?

I have no doubt that alcohol consumption, particularly in excessive quantities, is likely to present major impacts upon an individuals cognitive and emotional perceptions. It can also have negative impacts upon behaviour however; could those impacts be more pronounced in respect of (1) the susceptibility to or likelihood of someone suffering from PTSD and/or (2), after being clinically diagnosed with PTSD? Could the use of alcohol also present negative impacts on the prognosis for any expedient recovery?

Previous research has shown that alcohol (and drug) abuse commonly co-occur with PTSD[9]. In addition, there is a growing body of evidence that appears to show; recovery from PTSD (and/or other anxiety disorders) may be hindered, or the condition worsened, by medication or substance overuse, abuse, or dependence; resolving these problems can bring about a marked improvement in an individual’s mental health status and anxiety levels[10].

PTSD is a clearly a mental illness however; alcohol abuse can also present or be resultant of mental health issues. According to the NHS, the specific symptoms of PTSD[11] can vary widely between individuals, but generally fall into the categories described below.

Re-experiencing: the most typical symptom of PTSD. This is when a person involuntarily and vividly re-lives the traumatic event in the form of:
- Flashbacks
- Nightmares
- repetitive and distressing images or sensations
- physical sensations – such as pain, sweating, nausea or trembling

Some people have constant negative thoughts about their experience, repeatedly asking themselves questions that prevent them from coming to terms with the event.

For example, they may wonder why the event happened to them and if they could have done anything to stop it, which can lead to feelings of guilt or shame.

Avoidance and emotional numbing
- Trying to avoid being reminded of the traumatic event is another key symptom of PTSD. This usually means avoiding certain people or places that remind you of the trauma, or avoiding talking to anyone about your experience
- Many people with PTSD try to push memories of the event out of their mind, often distracting themselves with work or hobbies.
- Some people attempt to deal with their feelings by trying not to feel anything at all. This is known as emotional numbing. This can lead to the person becoming isolated and withdrawn, and they may also give up pursuing activities they used to enjoy.
Hyperarousal (feeling ‘on edge’)
- Someone with PTSD may be very anxious and find it difficult to relax. They may be constantly aware of threats and easily startled. This state of mind is known as hyperarousal.
- Hyperarousal often leads to:
  - Irritabilit
  - angry outbursts
  - sleeping problems (insomnia
  - difficulty concentrating
Other problems: Many people with PTSD also have a number of other problems, including mental health problems – such as depression, anxiety or phobias
- self-harming or destructive behaviour – such as drug misuse or alcohol misuse
- other physical symptoms – such as headaches, dizziness, chest pains and stomach aches
- PTSD sometimes leads to work-related problems and the breakdown of relationships.

I haven’t done the scientific stuff here but In conclusion I would offer the following opinions. These are based upon a combination of observations, experience and professional knowledge.

My ‘chicken & Egg’ analogy in the issues surrounding PTSD and alcohol abuse, although each have a correlation with the other, is mostly irrelevant.
The symptoms of PTSD are exacerbated by the excessive consumption of alcohol.
For any successful outcome when addressing PTSD and alcohol issues the patient must firstly recognise the issues at hand and secondly, take personal ownership of the desire to ‘recover’ from the problems he/she is experiencing.
Where there is a history of excessive alcohol consumption in a PTSD patient, irrespective of which came first, one issue won’t be addressed successfully without dealing with the other.

I look forward to any observations or comments from those suffering from PTSD and/or Alcohol issues, from those who work in either field or, anyone else who has an interest in the issues discussed. Hopefully this article, along with any resulting comments, will go some way towards helping to address the issues being examined.

References:

[1] Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events. Someone with PTSD often relives the traumatic event through nightmares and flashbacks, and may experience feelings of isolation, irritability and guilt. They may also have problems sleeping, such as insomnia, and find concentrating difficult. http://www.nhs.uk/conditions/post-traumatic-stress-disorder/Pages/Introduction.aspx

[2] Mind UK: Post Traumatic Stress Disorder (PTSD). https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd

[3] Drink Aware: Alcohol & Men. https://www.drinkaware.co.uk/check-the-facts/health-effects-of-alcohol/effects-on-the-body/alcohol-and-men

[4] Health & Social Care Information Centre (HSCIC): Statistics on Alcohol – England 2015. http://www.hscic.gov.uk/catalogue/PUB17712

[5] Health & Social Care Information Centre (HSCIC): Statistics on Alcohol – England 2015 http://www.hscic.gov.uk/catalogue/PUB17712

[6] Combat Stress UK. Myth Busters. http://www.combatstress.org.uk/veterans/myth-busters

[7] The Telegraph (August 2014) PTSD rises by a fifth in British Military. http://www.telegraph.co.uk/news/uknews/defence/11004038/PTSD-rises-by-a-fifth-in-British-military.html

[8] NICE Guidelines [CG26] – : Post Traumatic Stress Disorder: Management. http://www.nice.org.uk/guidance/cg26

[9] Maxmen, J. S.; Ward, N. G. (2002). Psychotropic drugs: fast facts (3rd ed.). New York: W. W. Norton. p. 348. ISBN 0-393-70301-0.

[10] Cohen SI (February 1995). “Alcohol and benzodiazepines generate anxiety, panic and phobias”. J R Soc Med 88 (2): 73–77. PMC 1295099.PMID 7769598

[11] NHS. Post Traumatic Stress Disorder – Symptoms. http://www.nhs.uk/Conditions/Post-traumatic-stress-disorder/Pages/Symptoms.aspx