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Comorbid PTSD

Comorbid PTSD refers to the co-occurrence of PTSD and other mental health and behavioral disorders.

What is Comorbid PTSD?

Comorbid PTSD is a blanket term for having a diagnosis of post-traumatic stress disorder (PTSD) in addition to other co-occurring disorders, such as anxiety, depression, addiction, or conduct disorder.

Many people who experience life-threatening traumas such as sexual abuse, natural disasters, combat, and childhood abuse develop PTSD, which in itself is a risk factor for developing mental health and substance use disorders.

Additionally, people with mental health or substance use disorders who experience a life-threatening traumatic event are at a higher risk of developing PTSD. PTSD is the most common trauma-related disorder, and the prevalence of developing a comorbid disorder is as high as 78%.

According to the American Psychological Association, over 80% of people with PTSD will experience at least one additional lifetime mental health disorder, and around 50% will experience three or more PTSD comorbidities.

What is PTSD?

PTSD is a mental health disorder that can occur after a life-threatening traumatic event when symptoms persist for longer than 30 days and interfere with daily life.

Symptoms of PTSD are categorized into five areas, which include:

Intrusion

  • Distressing nightmares related to the traumatic event
  • Distressing memories of the traumatic event
  • Flashbacks: A reenactment of the events

Negative mood

  • The inability to experience positive emotions such as laughter, joy, or humor

Dissociation

  • Having an out-of-body experience or altered sense of reality
  • The inability to remember important details about the traumatic event (dissociative amnesia)

Avoidance

  • Efforts to avoid emotions, feelings, or thoughts associated with the traumatic event

Arousal

  • Sleep disturbances
  • Problems concentrating
  • Irritable or aggressive mood or behavior
  • Increased startle response
  • Extremely sensitive to potential danger (hypervigilance)

A life-threatening traumatic event can affect people in many different ways. Some people may be able to process it and move on with their lives without any consequences. Other people may have nightmares or think about the trauma every so often. These life-threatening traumatic events can have a lasting effect on your life, and although it doesn’t always develop into PTSD, it can cause other mental health disorders.

Thinking about the trauma can bring up stress, sadness, and other emotions. When this starts to impact your daily life, it can be a cause for concern, as you may be developing a mental health disorder related to the trauma. You may also have comorbid PTSD but may not realize it because one disorder, such as depression, is masking the symptoms of PTSD. In that case, it is always wise to speak to a mental health professional as soon as possible for a comorbid PTSD assessment.

Common Mental Health Disorders Comorbid with PTSD

PTSD commonly co-occurs with other mental health disorders, with some studies showing that up to 90% of people with PTSD are also living with a PTSD comorbidity.

Common PTSD comorbidities include:

  • Depression
  • Anxiety
  • Substance use disorders
  • Obsessive-compulsive disorder
  • Disruptive disorders such as conduct disorder and oppositional defiant disorder

PTSD and Anxiety

PTSD shares many commonalities with anxiety. As a result, many people with PTSD also have co-occurring anxiety, specifically co-occurring generalized anxiety disorder. Other types of anxiety disorders include specific phobia, agoraphobia, panic disorder, and social anxiety disorder.

Anxiety is a lingering feeling of unease or fear, and in normal situations, it is the body’s reaction to a perceived threat. Once that threat is gone, the anxiety also dissipates. When an individual has an anxiety disorder, the symptoms of anxiety are still present even when the perceived or real threat is gone.

Anxiety disorders are not necessarily linked to traumatic experiences, meaning a person can be diagnosed with an anxiety disorder without having gone through a traumatic event. In contrast, a diagnosis of PTSD requires exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. While PTSD requires this type of extreme trauma, experiencing trauma, regardless of its severity, can still increase the risk of developing an anxiety disorder.

PTSD and anxiety share many similar symptoms including the following:

  • Negative thinking patterns
  • Sleeping difficulties
  • Avoidance behaviors
  • Irrational fears
  • Problems with concentration

Comorbid PTSD and Agoraphobia

Agoraphobia is an anxiety disorder characterized by the fear of being in a situation or place where it is difficult to escape, such as public transportation, enclosed spaces, or crowded places, and this fear produces symptoms of anxiety.

Agoraphobia, which is an example of avoidance, often presents with PTSD. For example, think of a young woman who was involved in a severe car accident. She developed PTSD from this incident and no longer drives on the freeway. She also started to avoid places where she felt she could be trapped, such as crowded grocery stores, subways, and airports, because thoughts of being in these places produced feelings of panic. This is an example of comorbid PTSD with anxiety, specifically agoraphobia.

Comorbid PTSD and Social Phobia

Social anxiety disorder, also known as social phobia, is an anxiety disorder marked by an intense fear of social situations where a person may be judged, embarrassed, or humiliated. This fear can lead individuals to avoid activities such as public speaking, group events, or even casual interactions in public. In some cases, the anxiety may also be tied to a fear of encountering reminders of past trauma. Over time, this avoidance can lead to isolation, loneliness, and impaired daily functioning.

For example, a combat veteran with PTSD may begin avoiding other veterans because they remind him of the traumatic experiences he endured during deployment. Although this avoidance initially centers on trauma-related triggers, it gradually expands to include a broader fear of social interaction. He begins avoiding support groups for people with PTSD, skips appointments at the VA, and withdraws from social events like birthday parties or community gatherings. This is an example of comorbid PTSD and social anxiety disorder, where trauma-related avoidance overlaps with a growing fear of social situations.

PTSD and Depression

Depression is the most common disorder that co-occurs with PTSD, and studies have shown that half of the people with PTSD have or have had depression. Depression is a risk factor for developing PTSD, as people with depression are more likely to experience traumatic events.

Additionally, a traumatic event is more likely to trigger an episode of depression, and therefore, PTSD is also a risk factor for depression; hence, these two disorders are closely connected.

Depression is characterized by feelings of sadness, guilt, isolation, lack of interest in hobbies, difficulty with concentration, problems with sleep, decreased energy, and suicidal thoughts or attempts. Lack of interest in hobbies, problems with sleep, decreased energy, difficulty concentrating, and depressed mood are also symptoms of PTSD. People with PTSD often become detached and isolated from their friends as a way to avoid people and situations that remind them of the traumatic event. Isolation and avoidance are also symptoms of depression.

PTSD and Addiction

People who use drugs and alcohol are at an increased risk of experiencing further traumatic events, and people who experience trauma are at an increased risk of misusing alcohol and drugs.

It’s common for people living with PTSD to develop unhealthy coping mechanisms as a way to blunt or hide their emotions and memories associated with the past traumatic event. Alcohol and drugs are often used as an unhealthy coping mechanism to help one numb the pain, try to sleep, and push out the intrusive thoughts and nightmares. They may even help alleviate these symptoms temporarily, but they will eventually do more harm than good.

Substance use disorders commonly co-occurs with PTSD and, over time, can make the intrusive thoughts and nightmares even worse. Drugs and alcohol are also known to exacerbate hypervigilance, depression, irritability, and social isolation. Addiction comes with a dangerous territory of symptoms that can be harmful to both the mind and body and be life-threatening in terms of overdose and withdrawal. Common drugs that are associated with comorbid PTSD include alcohol, heroin, marijuana, prescription opioids, cocaine, and benzodiazepines (prescription anti-anxiety medications).

PTSD and Disruptive Behaviors

Disruptive disorders are common but often overlooked PTSD comorbidities that occur as a result of past trauma. Individuals with disruptive behavior disorders often have past trauma and act out impulsively and aggressively because they have a difficult time with self-control due to how their past trauma affected them.

Disruptive behaviors are a group of disorders that are characterized by difficulty with impulse control, self-control, and aggressive behaviors. Therefore, these behaviors often threaten societal norms and others’ safety and are regarded as dangerous. Symptoms of these behaviors include lying, fighting, and rule-breaking. Oppositional defiant disorder and conduct disorders are the two most common disruptive disorders that co-occur with PTSD.

Other behavioral disorders include the following:

  • Intermittent explosive disorder
  • Pyromania
  • Kleptomania

Challenges in Comorbid PTSD Diagnosis

Diagnosing comorbid PTSD can be challenging because many of its symptoms overlap with those of other mental health disorders. For example, someone may be receiving treatment for PTSD but not showing improvement because they also have undiagnosed depression, or they may be treated for depression while an underlying PTSD diagnosis is missed.

A history of trauma is often a risk factor for many mental health disorders, and a person may not meet the diagnostic criteria for PTSD but can still be diagnosed with depression or anxiety and then later develop PTSD (delayed onset of PTSD symptoms). It can also be challenging to assess the impact and severity of the trauma, especially if the person does not want to discuss it out of fear of reliving the traumatic experience, and without a detailed history of the trauma, it can be challenging to make a thorough diagnosis.

Treatment for Comorbid PTSD

Treatment for comorbid PTSD includes a variety of psychotherapy approaches that involve addressing the underlying trauma and the symptoms and emotional impact that go along with it, in addition to providing other forms of therapy or treatment medication to help treat the co-occurring disorder. PTSD is best treated with the following approaches:

Medications are generally not used to treat PTSD but may be added to the treatment regimen when there is a comorbid condition, such as depression or anxiety. Depending on the co-occurring mental health disorder and the severity of the disorder, medications such as antidepressants (selective serotonin reuptake inhibitors) can help alleviate symptoms of depression and anxiety.

Anti-anxiety medications such as benzodiazepines can be used for very specific anxiety disorders, and medications can be used during the detoxification phase for certain substances such as alcohol, benzodiazepines, and opioids, as well as for the maintenance phase (long-term phase). When prescribing medications to help treat comorbid PTSD disorders, it is important to make sure that they do not interfere with symptoms of PTSD or with the psychotherapy approaches used to treat PTSD.

In general, comorbid PTSD conditions are treated at the same time to minimize symptoms of each disorder. For example, if depression is being treated, and PTSD is left unmanaged, symptoms of PTSD can worsen the symptoms of depression. However, when treating addiction and PTSD, the person needs to undergo detoxification in a supervised and safe setting before any underlying trauma is addressed. A person who is undergoing withdrawal or is under the influence of a substance is generally not in a healthy place to address their past traumatic events, and therefore, mental health professionals recommend that they go through detoxification before any long-term treatment can begin.

Living with Comorbid PTSD

It is possible to live a very healthy and fulfilling life with comorbid PTSD. Seeking professional treatment, having a strong social support system, and utilizing healthy coping mechanisms are the key ingredients to living with comorbid PTSD.

Some helpful tips for living with comorbid PTSD include:

  • Meeting with more than one mental health treatment professional and a variety of support groups. You may seek therapy for your PTSD from one treatment professional and be treated under a psychiatrist who can prescribe medications for your comorbid disorder.
  • Attending regular check-ins, therapy sessions, and support groups may be necessary to keep your symptoms under control.
  • Having loved ones in your circle who you can talk to, spend time with, and ask for help is key to being successful in this journey.
  • Taking time for yourself and practicing at least one thing each day that brings you joy, whether it is writing, gardening, going for a run, reading, or cooking. Self-care involves enjoying hobbies, eating nutritious food, getting adequate sleep, partaking in daily exercise, and setting routines that bring you peace.

Resources for People with Comorbid PTSD

Online resources

Books

Podcasts

If you are experiencing symptoms of PTSD or a comorbid mental health condition, it’s important to meet with your doctor or a mental health professional as soon as possible to get assessed.

If you are living with comorbid PTSD, remember that healing is possible. You can lead a healthy, fulfilling life with professional treatment, peer support, and coping strategies.

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