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Graduate Student Journal of Psychology                                                                             Copyright 2004 by the Department of Counseling & Clinical Psychology  
2004, Vol. 6                                                                                                                          Teachers College, Columbia University                          ISSN 1088-4661 
 
 
 

Posttraumatic Stress and Substance Use Disorders: A Biological and Clinical 
Summary 

 
David A. Fazzari 

Teachers College, Columbia University 
 

The comorbidity of post-traumatic stress disorder (PTSD) and substance use disorders (SUD) has 
been established in a number of studies, however treatment programs have historically focused on 
one disorder without considering the other. In addition to the growing clinical awareness of the co-
morbidity, there has been increased interest in its biological underpinnings and treatment options. 
This paper seeks to briefly review the biological processes involved, the interplay between symp-
toms, and examine two of the recent attempts at integrative treatment. 

 
 

The comorbidity of post-traumatic stress disorder 
(PTSD) and substance use disorders (SUD) has been estab-
lished in a number of studies (Breslau, Davis, Andreski, & 
Peterson, 1991; Kessler, Sonnega, Bromet, Hughes, & et 
al., 1995; Kulka et al., 1990; Resnick, Kilpatrick, Dansky, 
Saunders, & et al., 1993). For example, in studies of combat 
veterans with PTSD, alcohol abuse or dependence was the 
most common comorbid diagnosis. Other substance abuse 
or dependence also occurred at high rates in this population 
(Kessler et al., 1995; Kulka et al., 1990). In one study the 
comorbidity between alcohol abuse and PTSD was as high 
as 75% (Kulka et al., 1990).  

With growing awareness of the comorbidity, there has 
been increased interest in both its biological underpinnings 
and treatment options. This paper seeks to briefly review 
the biological processes involved and the interplay between 
symptoms, as well as examine two of the recent attempts at 
integrative treatment. 

 
Diagnostic Criteria 

 
Substance use disorders (SUD) vary in their presenta-

tion from substance to substance, but share certain common 
features. In this paper, SUD will include both substance 
abuse and substance dependence. Substance abuse is de-
fined as meeting one of the following criteria in a year: 
failure to meet obligations at work, school, or home as a 
result of use, engaging in dangerous behaviors while intoxi-
cated (such as drunk driving), recurrent substance use re-
lated legal problems, and continued substance use despite 
recurrent social or interpersonal problems (American Psy-
chiatric Association, 2000). Criteria for dependence involve 
meeting at least three of the following criteria: tolerance to 
the substance, withdrawal effects, taking the substance for  
 
 
Correspondence concerning this article should be addressed to 
David A. Fazzari. E-mail: damf11@yahoo.com 

longer or in larger amounts than intended, inability to con-
trol or reduce use, spending large amounts of time procur-
ing, using, or recovering from a substance, giving up major 
life activities in favor of substance use, and continued use 
despite the awareness of negative physical or psychological 
effects caused by or exacerbated by the substance (Ameri-
can Psychiatric Association, 2000). 

PTSD, by definition, is precipitated by either a direct 
threat to one’s life or physical integrity or witnessing such 
an act and is marked by feelings of fear, helplessness, or 
horror (American Psychiatric Association, 2000). PTSD 
symptoms consist of three clusters. The first is reexperienc-
ing symptoms such as flashbacks, nightmares, or intrusive 
recollections that may be caused by environmental cues 
associated with the trauma. The second group is character-
ized by avoidance of thoughts, feelings, or places associated 
with the trauma, as well as dissociation, restricted affect, 
and social withdrawal. The final symptom group involves 
increased arousal; which includes hypervigilance, difficulty 
concentrating, sleep dysfunction, or increased startle re-
sponse. War veterans and rape and incest survivors are 
grouped together in this discussion. Though there may be 
differences in their specific experiences, both trauma types 
must meet DSM-IV-TR criteria and both involve a “viola-
tion of pre-existing schemata of the self and the world, such 
as, that one is a good person and that the world is a safe and 
fair place where bad things do not happen to good people 
without reason” (Dye & Roth, 1991, p. 104). 
 

Biological Similarities 
 

On a biological and neurological level, a number of 
similarities have been found between PTSD and SUD. 
These disorders share two major systems: the hypotha-
lamic-pituitary-adrenal (HPA) axis and the noradrenergic 
system (though other systems are involved to a lesser ex-
tent). These two systems work simultaneously in response 
to stress during both substance use and PTSD (Jacobsen, 
Southwick, & Kosten, 2001). In the HPA system, stress 



COMORBID PTSD AND SUBSTANCE ABUSE 
 

 19

leads to an increased turnover of norepinephrine in the lo-
cus ceruleus and the discharge of the corticotropin-releasing 
hormone (CRH) in the pituitary portal system. These proc-
esses lead to the discharge of adrenocorticotropic hormone 
(ACTH, also referred to as corticotropin) in the pituitary, 
which in turn leads to a release of cortisol from the adrenal 
glands. Cortisol then in turn inhibits the production of 
CRH, creating a negative feedback loop (see figure 1; 
Austgen, Bowen, & Rouge, 2003).  

There is growing evidence that increased CRH is 
associated with anxious withdrawal symptoms and is a me-
diating factor in substance relapse (Jacobsen et al., 2001). 
Increased levels of CRH also have been shown to lead to a 
startle response, as seen in PTSD. Blocking the effects of 
CRH, on the other hand, prevents the development of with-
drawal associated behaviors related to anxiety. For example 
Jacobson et al describe a study which found that injecting 
CRH “reinstated heroin seeking after extinction in rats 
trained to self-administer the drug” (Jacobsen et al., 2001, 
p. 1186). 

The growing consensus at this time around the effects 
of chronic stress or PTSD on HPA axis function is that the 
“glucocorticoid negative feedback loop is enhanced in 
PTSD,” (Jacobsen et al., 2001, p. 1186) thus elevating 
CRH. This is of interest because CRH in the amygdala has 
been linked with fear-related behaviors such as the startle 
response. In addition, as mentioned earlier, elevated CRH 
has been implicated in stress related relapse. Therefore, 
CRH may be related to both hyperarousal and relapse. In-
terestingly, elevated CRH “enhances the euphorigenic 
properties of certain drugs, such as stimulants, and may 
worsen the severity of withdrawal symptoms, thereby 
prompting patients to relapse to drug use” (Jacobsen et al., 

2001, p. 1187). The opposite could also be true: that high 
levels of CRH caused by withdrawal may increase PTSD 
symptoms such as hyperarousal, which negatively effects 
mood and increases the chance of relapse. 

The second major system involved in PTSD and SUD 
is the noradrenergic system. When an individual experi-
ences chronic, uncontrollable stress, there is increased 
norepinephrine turnover in the brain (Jacobsen et al., 2001). 
The regions of the brain affected most are the locus ce-
ruleus, hypothalamus, amygdala, and cerebral cortex. This 
scenario has also been observed in individuals withdrawing 
from alcohol and opiates. 

The noradrenergic and HPA systems also interact with 
one another. For example, stress increases both CRH and 
norepinephrine via the amygdala and hypothalamus 
(Jacobsen et al., 2001). There has been some evidence that 
these two systems may increase one another, causing an 
increasing spiral of anxiety and hyperarousal related to 
PTSD, withdrawal, or both. 
 

Clinical Interaction 
The biological interplay between PTSD and SUD af-

fects the client and treatment in a number of ways. For ex-
ample, treating one disorder does not resolve the other, and 
often makes it worse (Najavits, 2002). Clients frequently 
abuse substances in an attempt to reduce PTSD symptoms 
and when an individual stops taking the substance, one of 
the major coping mechanisms is taken away. Furthermore, 
withdrawal symptoms are similar to and can exacerbate 
PTSD symptoms such as hyperarousal (Jacobsen et al., 
2001; Najavits, 2002).  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Figure 1.  

S 
T 
R
E 
S 
S 

Increased turnover of 
norepinephrine 

Corticotropin-releasing 
hormone (CRH) 

Locus Ceruleus 

Hypothalamus 

  ACTH released Cortisol 
released 

    Pituitary Glands    Adrenal Glands 

Cortisol inhibits CRH 



FAZZARI 
 

 20

In addition, SUD clients are at increased risk for 
trauma and PTSD sufferers are more susceptible to repeated 
abuse than someone who has not been traumatized in the 
past (Messman-Moore & Long, 2003; Najavits, 2002; 
Roodman & Clum, 2001).  

These and other factors can lead to a “downward spi-
ral” for the client. PTSD clients are at increased risk to de-
velop a SUD and SUD clients are at increased risk for 
trauma. As a client uses substances in response to PTSD 
symptoms, their SUD develops further. When entering 
treatment, the already difficult process of withdrawal is 
compounded by PTSD symptoms (Najavits, 2002). 

Integrative Treatments 

Seeking Safety 
This paper seeks to compare two of the recent empiri-

cally supported integrative treatments that have been devel-
oped: Substance Dependence PTSD Therapy (SDPT; Trif-
fleman, Carroll, & Kellogg, 1999) and Seeking Safety (Na-
javits, 2002). Seeking Safety’s title is derived from the au-
thor’s belief that safety is the most urgent and important 
need of people recovering from PTSD and SUD. “Safety” 
encompasses behaviors, thoughts, friends, and places in the 
client’s life. 

There are five central ideas underlying the Seeking 
Safety treatment. First, as stated above, safety is the priority 
of treatment. Second, the treatment is integrative, not 
merely an addiction treatment added on to a PTSD treat-
ment. Treatment of the two disorders is simultaneous, re-
gardless of which is predominant in the presenting com-
plaint. Third, there is a strong focus on creating meaning 
and living up to ideals. The fourth is that treatment consists 
of four areas: cognitive, behavioral, interpersonal, and case 
management. Lastly, the process of therapy and the thera-
pist are as important as the techniques that are imple-
mented. This includes attention to the dynamic issues in the 
relationship between therapist and client. Therapy is ex-
pected to last approximately six months. 

As mentioned above, four areas are targeted for inter-
vention. The cognitive techniques focus on relapse preven-
tion, such as problem solving and cognitive restructuring. In 
addition, there is a strong emphasis on compassion for self 
and others. Behavioral interventions include techniques 
such as activity scheduling, self-care, and behavioral ex-
periments. The goal is to make concrete steps, however 
small, during each session. These techniques, which can be 
applied to both disorders, are familiar concepts from relapse 
prevention (Marlatt & Gordon, 1985) and general cognitive 
behavior therapy (Beck, 1995). 

Seeking Safety also focuses on interpersonal issues. 
This is especially salient because the violence involved in 
PTSD is often interpersonal in nature and self-perpetuating. 
For example, an individual may be in an abusive relation-
ship (interpersonal situation) which may be a pattern that 
has been repeated since an initial childhood trauma (Mess-
man-Moore & Long, 2003). Furthermore, substance abusers 

are at higher risk for interpersonal violence (Najavits, 
2002). 

The last area of focus is case management. Because 
clients are often in need of a wide variety of services, it is 
important they have case management to help reconnect 
them to their communities and to take care of urgent needs 
such as food and shelter. Other case management needs 
may include medication management, vocational counsel-
ing, and domestic violence counseling. 

The treatment is also specific in which elements it does 
not include, such as Prolonged Exposure therapy (PE; Foa, 
Hembree, & Dancu, 1999). Najavits (2002) states that the 
treatment is focused on current life issues and does not 
dwell on the precursors that led to the diagnoses. There is 
also the additional concern that PE could trigger relapse, 
especially due to the time-limited nature of the treatment. In 
order to stay focused on the present symptom picture, this 
treatment does not recommend psychodynamic interpreta-
tions of the disorders. 

Substance Dependence Posttraumatic Stress Dis-
order Therapy 

Another recent empirically supported cognitive behav-
ioral approach is SDPT (Triffleman et al., 1999). The pri-
mary goals of treatment are abstinence through Cognitive 
Behavioral and Coping Skills Treatment (CBCST), contin-
ued abstinence during PTSD treatment, and reduced PTSD 
symptoms. It is a two phase treatment lasting approximately 
five months. The first phase, lasting 12 weeks and covering 
9 topics, is called “Trauma-Informed, Addictions-Focused 
Treatment” (Triffleman et al., 1999, p. 4) and focuses on 
abstinence, PTSD psychoeducation, PTSD symptoms, and 
the interaction between the two diagnoses within each par-
ticipant. Five of the topics have been adapted specifically 
for this dually-diagnosed population.  

The second phase, called “Trauma-Focused, Addic-
tions-Informed” (Triffleman et al., 1999, p. 5), focuses on 
an adaptation of PE and stress inoculation training (SIT; 
Foa, Rothbaum, Riggs, & Murdock, 1991). Phase II is di-
vided into two parts. The first section involves stress inocu-
lation training, which uses cognitive and behavioral strate-
gies to learn how to approach avoided stimuli, how to con-
front it, ways to cope when overwhelmed, and how to deal 
with any after-effects of the confrontation. The second por-
tion continues the SIT while conducting in vivo exposure. 
In vivo exposure is carried out much like Foa et al’s (1999) 
manualized treatment. Special attention is paid to develop-
ing the hierarchy of feared situations and implementing 
exposure in a slow and measured way so as to reduce the 
risk of relapse. 

SDPT allows for clinical judgment in transitioning an 
individual from Phase I to Phase II. Abstinence is preferred, 
but not mandatory, as long as progress has been made in the 
SUD treatment. The client must also be evaluated as to 
whether they are stable enough to endure the additional 
stress involved in Phase II.  



COMORBID PTSD AND SUBSTANCE ABUSE 
 

 21

Comparison of Treatments 
Both SDPT and Seeking Safety are strong empirically 

based treatments of PTSD and SUD. Though their format 
varies, the majority of the components overlap. Seeking 
Safety contains 25 topics, but several, such as Compassion, 
Recovery Thinking, and Create Meaning, could be con-
densed under a single heading of cognitive restructuring 
and core beliefs. The benefit of separating these topics may 
be to make them more palatable to the client (and clinician) 
and more easily absorbed, though this is not explicitly 
stated. 

Psychodynamic issues such as transference, counter-
transference, defenses, and projections are considered in 
both therapies. Because of the strong (often contradictory) 
feelings that traumatized and substance-abusing clients 
evoke in therapists, awareness of dynamic issues is critical 
(Daskovsky, 1998). However, both make the distinction 
that dynamic interpretations are not appropriate or produc-
tive for this type of treatment. In other words, awareness of 
the transference and countertransference is important for 
the clinician’s objectivity, but the analysis of such issues 
with the client is beyond the scope of these short-term 
treatments. 

The role of case management is highlighted to varying 
extents in both treatments. While Seeking Safety considers 
it one of the four core approaches, it is still well accounted 
for in SDPT. Both recognize that many clients who enter 
treatment are in need of a wide range of services that ther-
apy alone cannot provide. 

There are, however, a number of differences between 
treatments. First and most notably is the issue of in vivo 
exposure. Seeking Safety states that the risk of relapse due 
to the stress is too great to consider exposure treatment in 
this time limited format. Though similar in duration, SDPT 
makes in vivo exposure a core component of its program. 
SDPT allows for clinical judgment in deciding when to 
proceed, but the assumption is that the majority of clients 
can and will benefit from in vivo exposure. 

Seeking Safety does allow for in vivo exposure as an 
adaptation that can be undertaken by individual clinicians in 
longer-term treatment. Future research may indicate 
whether patients treated with SDPT experience significant 
relapses or drop out more frequently when compared to 
other treatments that do not include exposure. 

Another difference between the two therapies is Seek-
ing Safety’s emphasis on interpersonal issues. While SDPT 
includes interpersonal elements, Seeking Safety considers it 
tantamount in importance with cognitive and behavior 
methods. A third of the topics covered address interpersonal 
issues (Najavits, 2002). 

An additional variation is that Seeking Safety borrows 
some techniques from the growing psychological field of 
mindfulness treatment (Kabat-Zinn, 1990). Seeking 
Safety’s “grounding” techniques ask clients to notice every-
thing they can about the world around them. Increasing 
one’s awareness of the world around them and “de-

centering” oneself from one’s emotions is a central theme 
of this Buddhism-derived therapy (Lau & McMain, 2003).  

While both of these protocols advance the treatment of 
comorbid PTSD and SUD, they are still in the early stages 
of empirical testing. SDPT cites unpublished clinical trials 
that guided its development, but had no published clinical 
trials to date. Seeking Safety’s author, Najavits, has under-
taken studies to provide an empirical basis for her treatment 
(Najavits, 2000, 2002; Najavits, Weiss, & Liese, 1996; Na-
javits, Weiss, Shaw, & Muenz, 1998; Zlotnick, Najavits, 
Rohsenow, & Johnson, 2003). For example, in a sample of 
17 incarcerated women diagnosed with both PTSD and 
SUD 53% no longer met criteria for PTSD by the end of 
treatment (Zlotnick et al., 2003). Data on substance use was 
not very meaningful due to the reduced access to drugs in 
prison. In a study of 100 low-income women, Seeking 
Safety significantly reduced substance use and PTSD symp-
toms when compared to a control group receiving the ‘stan-
dard’ outpatient treatment (Najavits et al., 1998). However, 
a third group in this study was treated with relapse preven-
tion techniques (Marlatt & Gordon, 1985) and made similar 
gains to Seeking Safety, raising the question of whether 
Seeking Safety offers something above and beyond other 
current treatments.  

This initial research on the integration PTSD and SUD 
treatments has spurred other clinicians to develop empiri-
cally tested treatments. Most notable are Concurrent Treat-
ment of PTSD and Cocaine Dependence (CTPCD; Back, 
Dansky, Carroll, Foa, & Brady, 2001), which includes 
imaginal exposure in their treatment, and Transcend 
(Donovan, Padin-Rivera, & Kowaliw, 2001) which is a 
more intensive, partial hospitalization program developed 
for veterans.  

While many techniques are effective, Prolonged Expo-
sure (PE), which includes both in vivo and imaginal expo-
sure, has the greatest long term effect on reducing PTSD 
symptoms (Foa et al., 1991; Hembree, Rauch, & Foa, 2003; 
Taylor, 2003; Taylor et al., 2003; van Etten & Taylor, 
1998). It would seem useful to incorporate PE into a truly 
integrative treatment in order to fully address the PTSD 
symptoms, however, as mentioned before, this may increase 
the risk of relapse and drop out. It is necessary to have these 
treatments tested by other clinicians in other settings to set-
tle issues such as this. In addition, the author suggests that a 
component analysis be undertaken to elucidate which fac-
tors are most important for the reduction of symptoms. 

Conclusion 
The difficulties clients face from SUD and PTSD are 

enormous. Either disorder alone can be serious and debili-
tating. When combined, they complement each other in 
what appears to be a synergistic manner, with one disorder 
driving and reinforcing the other and vice versa. There is a 
strong comorbidity of these two separately formulated di-
agnoses that until relatively recently was overlooked. How-
ever, the anecdotal connection has been strengthened by 
biological and psychological research findings.   



FAZZARI 
 

 22

Both treatments are relatively new, though many of 
their components have been proven effective with other 
disorders. While future research may indicate one is more 
efficacious than the other, it seems that they hold much in 
common. The most significant difference, in this writer’s 
opinion, is the presence or absence of the PE component. 
However, because both treatments stress their flexibility, it 
seems that therapist preference and client presentation may 
be the best guide as to which treatment to choose at this 
point.  

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