PTSD and Substance Abuse in a Combat Veteran: A Case Study

Introduction and Research Informant Background

The research informant selected for this study is a 35-year-old soldier who was deployed in Iraq and served in the army for fifteen years. He has suffered from drug and alcohol addiction alongside post-traumatic stress disorder (PTSD) and is still battling both conditions at the time of this interview. When interviewing him, the clear purpose of this project was stated without ambiguity, and he was informed of his voluntary participation and his consent to allow all provided data to be used. He was reassured of the complete privacy of his responses and that all data would be kept confidential. For example, he was told that his name would never be recorded and that no researcher would ever have access to it; instead, he was assigned a number. Furthermore, while his interview was being recorded, it was made clear that his image would never be captured — only his voice.

The purpose of the project was stated as clearly as possible: to understand the nuances and factors that contribute to PTSD, and to understand why substance abuse is such a common factor among people who struggle with PTSD. Many of the interview questions were taken or adapted from the Clinician-Administered PTSD Scale (CAPS) for DSM-IV. Before the interview began, the participant was warned that he would be asked questions that might make him uncomfortable, or that touched on some of the more stressful and difficult experiences people can have. He was told that these questions might upset him and that it was entirely his choice how much he wanted to share. He was also told that if he began to feel uncomfortable, he should let the interviewer know so that the pace could slow down and his feelings could be discussed.

PTSD Assessment Using the CAPS Scale

The portion of the interview drawn from the Clinician-Administered PTSD Scale for DSM-IV was structured as follows: the participant was asked to discuss a particularly distressing event and to share issues with recurring images, thoughts, or perceptions connected to that event. One representative question read:

"Have you ever had unwanted memories of [EVENT]? What were they like? What did you remember? Did they ever occur while you were awake, or only in dreams? [Exclude if memories were just in dreams.] How often have you had these memories in the past month?"

The response scale ranged from 0 (Never) to 4 (Daily or almost every day). For this question and all comparable questions, the participant answered with a 4 — daily or almost every day.

A second line of questioning addressed the intensity of these memories:

"How much distress or discomfort did these memories cause you? Were you able to put them out of your mind and think about something else? How hard did you have to try? How much did they interfere with your life?"

The response scale for this item ranged from 0 (None) to 4 (Extreme — incapacitating distress, cannot dismiss memories, unable to continue activities). For this question and all others like it, the participant answered with a 4, indicating that he was experiencing extreme distress on a daily basis.

Questions of this kind help to establish a clearer picture of what the participant deals with each day and how much his memories interfere with normal functioning. However, the interview also included discussion of the participant's specific background in order to gain broader perspective on his developmental history.

Life History and Developmental Context

This participant comes from a lower-middle-class rural background in a small town in North Carolina. His father left when he was five years old, and his mother remarried twice. The stepfather who raised him was a truck driver who was frequently absent. His upbringing was marked by parental instability, as neither biological nor stepparents provided a consistent presence in his life.

The participant suffers from flashbacks, one of the most debilitating symptoms of PTSD. As the National Institute of Mental Health explains, most PTSD sufferers repeatedly relive trauma through intrusive thoughts during the day and nightmares during sleep. These flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences — a door slamming, a car backfiring, or being in a place that resembles the site of the original trauma. A person experiencing a flashback is likely to feel the same emotions and physical sensations that occurred at the time of the incident, despite being safe in the present moment. This is one of the primary challenges this participant faces, and it has caused his quality of life to deteriorate significantly, leaving him feeling as though he has no control over his emotions or sense of safety.

If his life were structured like a chapter book, the participant's history might be divided as follows: Chapter one covers the pain of being abandoned by his father and witnessing his mother's suffering. Chapter two describes the discord of two subsequent marriages, always wondering whether the next stepfather would also leave. Chapter three focuses on acting out as a child — smoking, drinking, and experimenting with drugs. Chapter four covers enlisting in the army after failing to finish high school. Chapter five describes finding a genuine sense of belonging and camaraderie among fellow soldiers, and experiencing for the first time a feeling of power, control, and accomplishment. Chapter six recounts being kidnapped in Iraq and witnessing a fellow soldier be tortured and killed. Chapter seven follows his discharge and return to America, where he felt entirely out of place, finding solace first in pills and alcohol, and then spiraling into dependency.

One of the major ongoing stresses this participant faces is his heavy reliance on prescription pills and alcohol as coping mechanisms for pain, stress, and anxiety. He feels deeply ashamed of this dependency, yet continues to use these substances regardless — adding a layer of shame and self-reinforcing stress to an already overwhelming situation.

Experts have found that PTSD symptoms are generally more severe when the trauma was inflicted by another person, making this participant's circumstances particularly difficult. He has described a profound sense of helplessness — a feeling that the past is actively shaping the present in destructive ways and that nothing can be done to change it. The one thing he says keeps him going is his dog and the hope of one day reconnecting with former soldiers. He has lost contact with all of his friends and no longer maintains relationships with family members. A deep fear of abandonment, rooted in the instability of his childhood, continues to impact him. This sense of worthlessness pushed him toward acting out in youth, yet paradoxically it was the army — with its rigid structure — that gave him his first experience of genuine belonging. The trauma of combat ultimately shattered that stability, leaving him in a persistent state of limbo and loss of control.

References

Berger, K. (2009). Invitation to the Life Span. New York: Psychology Press.

Ptsd.va.gov. (2013). Clinician-Administered PTSD Scale (CAPS). Retrieved from http://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp

Schmahl, C. (2004). Psychophysiological reactivity to traumatic and abandonment scripts. Psychiatry Research, 33–42.

Walker, P. (2013). Managing abandonment depression in complex PTSD. Retrieved from http://www.pete-walker.com/managingAbandonDepression.htm

Wilson, J. (2012). Treating Psychological Trauma and PTSD. New York: Guilford Press.