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DURHAM, NC — Posttraumatic stress disorder (PTSD) has been estimated to affect 12.9% of U.S. veterans, compared to the lifetime risk of PTSD in the general population, which is estimated at 6.8%.
Among PTSD patients, substance abuse disorders (SUDs) are common, according to an article in the Journal of Dual Diagnosis, which added that panic attacks—abrupt and intense surges of physiological discomfort and distress, such as racing heart, respiratory changes and trembling—also frequently co-occur with both SUDs and PTSD. But the complex relationship between panic and comorbid PTSD/SUD has not been thoroughly examined, according to the study, which suggested that undiagnosed panic among people with PTSD/SUD could potentially diminish long-term outcomes for patients by interfering with other therapies.
Furthermore, most studies that have examined the relationship between PTSD and SUD combine people with alcohol use disorder (AUD) and drug use disorders (DUDs) into a single “SUD” group. This is potentially problematic, explained researchers from the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center in Durham, NC, and VA Puget Sound Health Care System in Seattle, as other experts have highlighted important differences between SUD patients who only use alcohol vs. those who use drugs (with or without alcohol).
To better understand whether panic is associated with greater likelihood of SUDs among people with PTSD and to tease apart AUD and DUD diagnostic risk among people with comorbid PTSD/SUD, the VA researchers analyzed national data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a cross-sectional national study. They classified 2,230 adults with lifetime PTSD into one of three groups based on diagnostic interview data: adults with PTSD/AUD (i.e., they met the criteria for PTSD and AUD but not DUD); adults with PTSD/DUD (i.e., met criteria for PTSD and DUD, which included cannabis, sedatives/tranquilizers, heroin/opioids and cocaine, regardless of whether they also had AUD), or adults with PTSD-only (i.e., met criteria for PTSD but not AUD or DUD).1
Weighted logistic regression analysis adjusting for demographic characteristics and PTSD symptom count (as an indicator of PTSD symptom severity) showed that lifetime risk of PTSD/AUD and PTSD/DUD, each relative to PTSD-only, was greater for adults who were younger at the time of data collection, were male, and had a lifetime history of panic attacks.
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Consistent with other epidemiological and clinical studies, the researchers found that alcohol, cannabis, and opioids/ heroin were the most commonly endorsed DUDs among their sample of adults with PTSD. One possible explanation they noted in their study was that these substances might be relatively easy to access and afford, compared to other psychoactive substances. In the United States, alcohol is legal for adults 21 years and older, cannabis is legal in many states, and opioids are legal with a valid prescription (as are sedatives/tranquilizers).
Contrary to the researchers’ hypotheses, panic attacks were not found to be significantly associated with higher lifetime risks of specific DUDs, such that, after adjusting for PTSD symptom count and number of other comorbid lifetime SUDs, panic attacks were not associated with greater odds of having lifetime diagnoses of cannabis, sedative/tranquilizer, heroin/opioid or cocaine use disorder. “Such findings suggest that these four DUDs are more strongly related to SUD severity (i.e., polysubstance use) than panic or PTSD symptoms in particular and highlight the complexity of identifying substance-specific DUD risk factors among people with PTSD/DUD,” they wrote.
Lastly, compared with females, males had nearly two times greater odds of having lifetime PTSD/AUD and nearly three times greater odds of having lifetime PTSD/DUD, which is also consistent with previous epidemiological studies, the researchers reported. Thus, while women are more likely than men to develop PTSD in general, this study’s findings suggest that men who do develop PTSD are also more likely to develop AUD and DUDs.
The authors noted that this study was limited by its use of a cross-sectional design, meaning that they cannot infer causality from their findings or make definitive conclusions regarding the direction of the relationships between panic, PTSD and SUDs.
One implication of these findings is that PTSD/SUD treatment outcomes might be improved if providers assess for panic and incorporate panic intervention strategies into the PTSD/SUD treatment plan, the authors suggested. This is because previous researchers have argued that panic attacks can leave patients with PTSD and SUD vulnerable to relapse of symptoms if their panic is not sufficiently addressed. The researchers said their findings point to the potential clinical benefits of systematically evaluating the role of panic during PTSD/SUD treatment in future research.
- Blakey SM, Campbell SB, Simpson TL, Associations Between Lifetime Panic Attacks, Posttraumatic Stress Disorder, and Substance Use Disorders in a Nationally Representative Sample. Journal of Dual Diagnosis. Published December 29, 2021. doi: 10.1080/15504263.2021.2013096