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Recovery: Substance Abuse.

Q: Dear Frank, We received a question about substance abuse. The reader reports her sobriety through AA -- and she asks, "Why do most people say do not drink alcohol if you have PTSD? Stopping drinking certainly does not take it away."

A: Dear Joyce,

Thank you for sending me this reader's question. It is a good question and a valid observation.

Alcohol is the most common self-medication for PTSD because it reduces awareness, blunts traumatic memory, helps with insomnia, and allows inhibited people to socialize. It covers-up the reality that caused PTSD and it delays the hard work of dealing with that reality. Most of my patients with PTSD have used alcohol before coming to see me. Usually, they have reduced their drinking by the time they reach me because they have decided to help themselves.

I value AA and all other proven approaches to sobriety, because alcoholism prevents serious work on the issues that cause PTSD and on the deficits that result from PTSD. Alcohol by itself is not the problem. Many people with PTSD can drink, in moderation. But alcoholism, by definition, is a condition in which the use of alcohol has reached levels that interfere with successful life, whether that means being a good parent, partner, worker or friend.

PTSD, unrecognized and untreated, may be the driving force behind alcoholism. It certainly was with my most recent patient, a veteran who nearly lost his marriage because he drank to avoid flashbacks, insomnia and a bitter feeling of neglect. But he lost his need for excessive alcohol once he decided to get professional help for his PTSD. He became optimistic about reducing his symptoms. He accepted medication for depression and insomnia. The whole cycle improved, including morale, performance and PTSD symptoms.

It is not unusual for PTSD to be more of a problem when alcohol use is curtailed. A drug that reduces rational thought has been taken away. Part of PTSD is the painful recognition of loss, vulnerability, shame and guilt. PTSD also includes too-realistic memory and too-intense anxiety. For these reasons, professional therapy may be needed to substitute manageable medication for self-medication, and to coach a survivor in ways to cope. PTSD treatment should be very practical and should begin with effective attention to pressing personal needs.

Some additional thoughts on why therapists ask clients with PTSD to ease up on alcohol intake, and, in some cases, eliminate alcohol completely:

1. If a person is a problem drinker, alcoholism interferes with mature, thoughtful relationships. This is true whether or not PTSD is present. Angry people get more angry and may become violent when inebriated. Withdrawn people may become more morose, reclusive and self-destructive. Suspicious people may become paranoid, seeing threats that aren't there. Careless and impulsive people may have accidents, misjudging their abilities to operate machinery, particularly motor vehicles, in a safe manner.

2. When the tendencies mentioned above are combined with PTSD symptoms, every negative outcome is multiplied. PTSD makes angry people angrier, reclusive people more withdrawn, anxious people more suspicious, and careless people more confused. PTSD symptoms include irritability, numbing, avoidance, hyper-vigilance and concentration deficit. It is easy to see how alcohol worsens many PTSD problems, particularly those that interfere with intimacy and trust.

3. Alcohol may complicate drug treatment. Booze is a CNS depressant. That means it reduces the activity of the central nervous system (brain function, overall). Some troubled people seek this dampening of brain activity because their minds are delivering bad dreams, bad memories and the bad sensations of fear, arousal and guilt. But proper medication for depression, anxiety and insomnia is far more effective than alcohol, without the damaging side-effects. Alcohol, in moderation, will not interfere with these prescribed medications--unless the combination occurs early in the course of treatment, when the body is still adjusting to the drug. Some doctors simply say, "no alcohol allowed." Some are more tolerant, talking through the way to include careful drinking as part of recovery from PTSD.

Freedom from the disabling symptoms of PTSD is such a relief. Reducing alcohol intake is almost always a significant step toward that relief. But it often requires the guidance and support of a professional who understands the treatment of both PTSD and alcoholism.

So I'll answer the reader's question by saying that the advice to stop drinking if you have PTSD is good advice if you are ready to face the source of your PTSD and to do something about the consequences of PTSD. Being honest with yourself places you on the path to recovery. There are many good people on that path: family, friends and professionals who will offer respect and support.

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