Understanding the

Link Between Trauma

and Addiction
Amanda L. Giordano, PhD, LPC
University of Georgia
[Link]@[Link]
 Presentation Agenda

• How do drugs and addictive behaviors

affect the brain?
• Why does trauma increase the risk of
addiction?
• Adverse Childhood Experiences (ACEs)
and addiction
• Clinical approaches for treating trauma
and addiction simultaneously
• Questions and Resources
 The Heart of Addiction

People with addiction are

addicted to changing the way
that they feel.

• Both drugs of abuse (cannabis, alcohol, methamphetamines,

nicotine, cocaine, etc.) and behavioral addictions (gaming,
gambling, sex, social media, food, etc.) can change the way a
person feels
 Why do Drugs and Certain
Behaviors Feel Good?
• Drugs of abuse and behavioral addictions activate reward circuitry
in the brain and stimulate the release of dopamine and other
neurotransmitters implicated in reward, pleasure, calm, and euphoria
• Mesolimbic dopaminergic pathway
• Individual is motivated to seek out activities that are rewarding (Schultz,
2015).
• “Rewards with stronger effects on dopamine neurons are likely to have
more impact on learning and choices” (Schultz, 2015, p. 937)
• Over time, the brain adapts (neuroadaptations = changes in brain due
to experience; Doidge, 2007) and a person needs more of the drug
or longer engagement in the behavior to achieve the desired effect
(tolerance)
 Why do Drugs and Certain
Behaviors Feel Good?
• Drugs of abuse and behavioral addictions are both
positively and negatively reinforcing
• Positively reinforcing: add something desirable (e.g.,
pleasure) to increase the odds of engaging in the behavior
in the future
• Negatively reinforcing: remove something undesirable
(e.g., anxiety) to increase the odds of engage in the
behavior in the future
• Drugs of abuse and behavioral addictions are
• Predictable and reliable forms of emotion regulation (at
least initially)
 Example: Cocaine
• Cocaine is a stimulant (excites the central nervous
system; causes energy and euphoria)
• Interferes with the transporter molecules that remove
dopamine from the synapse (Neslter, 2005)
• Rather than being reabsorbed and deactivated, cocaine
blocks the process of dopamine reuptake
• Dopamine remains active, enhancing the experience of
reward
• Cocaine is pleasurable and reinforcing (Nestler, 2005;
Wise & Robble, 2020)
 Example: Pornography

• Pornography is a supernormal stimulus (artificial, exaggerated

version of a natural instinct; Barrett, 2010)
• Available, free, always accessible, anonymous, unlimited “partners”
• Causes the release of endogenous chemicals (neurotransmitters and
hormones originating inside the body) in the reward pathway
• As a supernormal stimulus, can cause more dopamine stimulation and
become more rewarding than natural rewards (Barrett, 2010)
• While an individual may run out of drugs of abuse, internet
pornography is endless and users can activate their reward
circuitry for hours
Why might someone
who has experienced
trauma have a
heightened risk for
using drugs of abuse
or engaging in
addictive behaviors?
 Symptoms of PTSD
• Recurrent, intrusive, distressing • Persistent negative emotional state
memories and/or dreams of trauma
• Diminished interest in activities
• Dissociation • Feelings of detachment from others
• Flashbacks (feel as if traumatic event • Inability to experience positive
is recurring)
emotions
• Intense psychological distress and • Angry outbursts
physical reactions when exposed to
trauma cues • Hypervigilance
• Persistent and exaggerated negative • Exaggerated startle response
beliefs about self, others, world
• Sleep disturbances
• Self-blame
(APA, 2013)
 Stimulants

Types of Effects on the

Stimulants Body
Cocaine Excite the central
Amphetamines nervous system
Methamphetamine Energy
Nicotine Euphoria
Increased movement
and talkativeness
Decreased appetite
Insomnia
 Depressants
Types of Effects on the
Depressants Body
Alcohol Euphoria
Barbiturates Decreased anxiety
Benzodiazepines Reduced distress
Memory impairment
Sense of calm
Relaxation
Slowed reaction time
Lowered inhibitions
Poor coordination
 Opioids
Types of Opioids Effects on the
Body
• Natural: opium, Euphoria
morphine, codeine Dream-like state
• Semi-synthetic: heroin, Sedation
hydrocodone, Drowsiness
oxycodone, Percocet, Pain-relief
Vicodin
• Fully-synthetic:
methadone, fentanyl
 Cannabis

Forms of Cannabis Effects on the Body

Blunts/joints/vaping Sedation
(smoked marijuana) Dreamy relaxation
Hashish (resin from Interpersonal
hemp plant) closeness
Hash oil (dabbing) Impair memory and
Edibles learning
Paranoia/delusions
Poor coordination,
reaction time, and
judgment
 Behavioral Addictions

Shopping Gaming Gambling Social

Media

Pornography Exercise Nonsuicidal Work

Self-Injury

Sex Love Food Internet

 Self-Medicating with Drugs of
Abuse or Addictive Behaviors
• Trauma history = higher risk of self-medicating or “dulling the inner world”
(Van der Kolk, 2014, p. 268) using addictive substances and behaviors
• Some drugs of abuse have a calming intoxication effect (benzodiazepines,
alcohol, opioids, and marijuana), and behaviors such as gaming and gambling
produce a “trance-like” state, which may be used as a means to escape chronic
stress and hypervigilance
• Sex, exercise, stimulants (nicotine, cocaine, meth, ADHD medications) have an
excitatory effect and be used as means to “feel something” when numb and
detached
• Cortisol (stress hormone)- linked to eating behaviors (craving for high-sugar or
high-fat foods)
• Nonsuicidal self-injury as a means of anti-dissociation
 Prevalence of Trauma Among
those with Addiction
• Meta-analysis of 10 studies: among those with substance use
disorder, childhood maltreatment was markedly higher than those in
the general population (Zhang et al., 2020)
• Among 172 youth entering substance abuse treatment, 71.5%
reported experiencing at least one traumatic event (Cole et la., 2019)
• Among adults in outpatient substance use treatment, 85.1%
experienced at least one traumatic event (Giordano et al., 2016)
• Among university students, researchers found a direct relationship
between childhood trauma and internet gaming disorder (Shi et al.,
2020)
 Adverse Childhood Experiences
• ACEs: Traumatic or stressful events during first 18 years of life
• Abuse (emotional, physical, sexual)
• Neglect (emotional, physical)
• Witnessing violence in the home
• Living in a home with active addiction
• Living in a home with untreated mental illness
• Separation (divorce, incarceration)
• Criminal behavior
• ACE Score- sum of ACE categories (0-10); Dose response
• In a study of over 17,000 people, 12.5% had 4 or more ACEs
(CDC-Kaiser study; Felitti et al., 1998)
 Toxic Stress
• Stress response is healthy and supports survival
• Hypothalamic-Pituitary-Adrenal (HPA) axis
• Stress hormones (adrenaline and glucocorticoids)
• Fight or flight mode (hyperarousal)
• On the other hand, toxic stress is strong, unpredictable, and
prolonged; occurring in the absence of buffering from caring adult(s)—
can be the result of ACEs (Burke Harris, 2018)
• The threat/danger is persistent, thus the stress-response system is
chronically activated
• Elevated stress hormones, hyperarousal, anxiety, hypervigilance, alert (van der
Kolk, 2014)
 Toxic Stress
• Elevated stress hormones in the body can lead to
insomnia, increased blood sugar, inflammation,
cardiovascular disease, compromised immune
system (Guilliams & Edwards, 2010)
• Early trauma can disrupt oxytocin regulation
(hormone implicated in emotional intimacy and
attachment) and serotonin (neurotransmitter
linked to mood; De Ballis & Zisk, 2014)
• Dysregulated stress response system can make it
difficult to regulate emotions, cope, or self-
soothe
 Increased Risk for Addiction
• Individuals with dysregulated stress responses due to
early trauma may seek to regulate their heightened
emotional states (e.g., hyperarousal, vigilance, fear,
anxiety) by engaging in addictive behaviors or using
drugs of abuse
• “The linking mechanisms appear to center on
behaviors such as smoking, alcohol or drug abuse,
overeating, or sexual behaviors that may be
consciously or unconsciously used because they have
immediate pharmacological or psychological benefits
as coping devices” (Felitti et al., 1998, p. 253)
 ACEs and Addictive Behaviors

ACE Alcohol Drug Ever Severe 50 or more Problem

Score Use Problem injected Obesity sexual gambling
Disorder (Dube et drugs (Felitti et partners (Poole et
(Dube et al., 2003) (Felitti et al., 1998) (Felitti et al., 2017)
al., 2002) al., 1998) al., 1998)

0 2.5% 1.3% 0.3% 5.4% 3.0% 15.2%

4+ 9.7% 7.5% 3.4% 12.0% 6.8% 39.9%

 Trauma and Affect Dysregulation

• Thus, trauma may lead to

difficulties in emotion regulation
• Many studies indicate that
individuals with difficulties
regulating emotions are at higher
risk of using drugs of abuse or
engaging in addictive behaviors
(Dingle et al., 2018; Prosek et al.,
2018; Estevez et al., 2017; Cashwell
et al., 2017)
 Trauma and Emotion Regulation
Difficulties

Emotion
Trauma Addiction
dysregulation
Trauma Addiction
 What is the Answer?
• Integrated treatment: simultaneously addressing trauma and
addiction
• Better outcomes than addressing one issue (e.g., trauma) and then
the other (e.g., addiction)
• “Substance abuse counselors are not typically trained to work on severe
mental health problems, and thus PTSD may be ignored or
misunderstood. Similarly, most mental health therapists are not trained
to work on substance abuse” (Najavits, 2002, p. 4)
• Advocacy issue: access to quality treatment and integrated care?
• Delaware Drug Overdose Fatality Review Commission: among those
who died of a drug overdose, 37.4% self-reported experiencing at least
one traumatic event
• 8.5% reported receiving counseling (Lawes, 2022)
 Seeking Safety (Najavits, 2002)
• Understand interaction between substance use and trauma symptoms;
interrelated; trigger each other
• Using heroin to escape trauma flashbacks
• Sometimes abstinence leads to worse trauma symptoms
• Treatment topics (25) are relevant both to substance use and trauma
• Group or individual format
• Central ideas: safety is the initial goal, integrated treatment to address
trauma and substance use, cognitive, behavioral, interpersonal, and case
management focus
• Seeking safety does not require the exploration of the trauma or trauma
narrative
 What is Safety? (Najavits, 2002)

• The priority of Seeking Safety is to initiate

safety in the client’s life:
• Manage trauma symptoms
• Cope with life without substances
• Take care of the self and feel good about the
self
• Find a safe, support system
• Discontinue self-destructive behaviors
• Foster self-respect
 Seeking Safety (Najavits, 2002)
• Examples of treatment topics:
• Safety • Setting boundaries in
relationships
• Grounding
• Coping with triggers
• Asking for help
• Healing from anger
• Compassion
• Self-nurturing
• Recovery thinking
• Integrating the split self
• Creating meaning
 Example Session: Detaching from
Emotional Pain (Grounding)
• Purpose: teach grounding exercises (mental, physical, soothing);
grounding helps clients shift focus to the external world and present
moment rather than painful internal feelings
• Grounding can help detach from drug cravings or intense trauma-related
negative feelings
• Session format: check in, review quote, teach and demonstrate
grounding, apply skill to clients’ lives, check out
• Facilitate an in-session demonstration of grounding
• Mental: focus the mind, Physical: focus the senses, Soothing: kind self-talk
• Grounding can be utilized anywhere, any time, when faced with a trigger
• Process clients’ reactions to grounding, what method they will try,
when it can be useful
 Examples of Grounding
• Mental • Mindful eating
• In your mind, describe all the details • Touch objects of various textures
of your immediate environment
• Soothing
• Think of as many members of a
category as possible (e.g., types of
• Picture a person or people you care
about
plants)
• Focus on an image that depicts some • Say a kind statement about yourself
(“I am strong and resilient”)
sort of separation from the pain
• Say a coping statement (“I can get
• Physical through this”)
• Wash your hands in warm water
• Stretch your body
 Other Approaches to Address
Trauma and Addiction
• Trauma Recovery Empowerment Model (TREM)
• Female trauma survivors with substance use disorders; manualized group
intervention
• CBT techniques, coping skills training, psychoeducation
• Empowerment: self-control, boundaries, self-monitoring
• Trauma: experience and consequences
• Skill Building: decision making, self-regulation, healthy relationships
• Addictions and Trauma Integration Model (ATRIUM)
• 12-sessions for groups or individuals (all genders)
• Abuse survivors with substance use problems or behavioral addictions
• Expressive arts and mindfulness practices; heal body, mind, and spirit
 Treating Addiction and Trauma:
Emotion Regulation Enhancement
• Individuals with trauma histories and addiction
can benefit from emotion regulation skills
training
• Emotion regulation is an individual’s ability to
influence their emotional reactions using internal
and external strategies (Gross, 1998; Thompson,
1994)
• Emotion regulation processes can modify the
intensity, timing, quality, range, duration, and
recovery from emotional experiences
(Thompson, 1994)
 Emotion Regulation Strategies
• Organizing one’s life in such a way as to increase the probability of positive
emotional experiences and decrease the probability of difficult emotional
experiences (e.g., regulating one’s environment; Thompson, 1994)
• Modifying one’s current situation to change its effects on emotional
experiences (Gross, 2014)
• Modifying what one attends to in unavoidable situations (e.g., redirection,
distraction; Gross, 2014; Thompson, 1994)
• Adjusting one’s cognitive appraisal of a situation (Gross, 2014) or modifying
“one’s interpretation of emotionally meaningful information” (Thompson,
1994, p. 35)
• Modifying emotional responses and selecting a different emotional
expression (e.g., employing adaptive coping strategies to alter one’s mood;
Gross, 2014; Thompson, 1994)
 Questions, Comments, and To Learn More

• [Link]@[Link]
• Facebook author page:
• [Link]
mandaleegiordano
• Psychology Today Blog:
Understanding Addiction
• [Link]
com/us/blog/understanding-
addiction