Study: PTSD Found in 84% of Adults with ADHD Seeking Treatment for Alcohol Use Disorder
Results of a study of inpatients with alcohol use disorder point to a link between ADHD and a form of PTSD more severe than that found in patients without ADHD. Further research is needed to establish a correlation in people not hospitalized.
May 18, 2020
Post-traumatic stress disorder (PTSD) is almost ubiquitous in adults with attention deficit hyperactivity disorder (ADHD) who are seeking treatment for alcohol use disorder (AUD), according to a new study of 551 hospital patients in France. Researchers studied patient questionnaires factoring in age, gender, marital status, lifetime trauma exposure, and self-reported adult ADHD; the results confirmed that PTSD was highly correlated with ADHD in patients hospitalized for AUD and may indicate a specific subpopulation.
This research is the latest in a growing number of studies that reveal an association between ADHD and PTSD in both children and adults.1 The DSM-5 establishes 17 symptoms of PTSD that occur in the aftermath of a traumatic event and impact between 4.8% and 8% of the population. 2 In individuals with AUD, the prevalence of PTSD is estimated at 20% and 39%.3,4
The recent French study was conducted on patients with AUD — mostly police officers and employees of the French Ministry of the Interior — in treatment between January 2016 and October 2017 at Le Courbat, an addiction rehabilitation center in France.
AUD and PTSD Through the Lens of ADHD
ADHD has long been associated with early alcohol consumption, risky use of alcohol, AUD, and substance use disorder (SUD). Research suggests that the prevalence of ADHD in adults with AUD ranges from 19.9% to 33%.5 This population is also more prone to alcohol relapses.
The comorbidity of PTSD and ADHD in children and adults has been established in a growing body of literature. Some prospective studies suggest that patients with ADHD who experience traumatic events are more likely to engage in risky behavior related to ADHD impulsivity and difficulty around planning.6,7
A review of 22 studies examining the relationship between ADHD and PTSD found a somewhat greater risk for PTSD in patients with ADHD than vice versa (2.9 compared with 1.7). These findings indicate a bidirectional link between the two disorders. 8,9 Previous data also suggest PTSD is associated with higher levels of childhood and adult ADHD.
Details of the ADHD, PTSD, and AUD Study
To better understand the trauma experienced by the patients in the French study, the questionnaire gauged exposure to 17 possible traumatic events, separated into five different categories: catastrophes, accidents, physical aggressions, sexual aggressions, and life-threatening events.
ADHD was assessed using the six-item Adult ADHD Self-Report Scale (ASRS) version 1.1 and the 25-item Wender Utah Rating Scale (WURS). 10,11 For the purposes of the study, significant scores on both scales established adult ADHD. PTSD was assessed following the checklist of the DSM-5.
The questionnaire results revealed the following:
- One third of the sample met the criteria for self-reported childhood ADHD
- 20% met the criteria for adult ADHD
- 49% met the DSM-5 criteria for the diagnosis of PTSD
- 3% met the criteria for ADHD but not PTSD
- 33% met criteria for PTSD but not ADHD
- 17% met the criteria for both ADHD and PTSD
- 97% of the participants experienced at least one traumatic event. The most common categories were: accidents (77%), physical assaults (69%), and unspecified trauma (71%). Sexual assault had been experienced by 20%.
ADHD and PTSD Study Conclusions and Bias
Researchers found a significantly higher prevalence of PTSD in inpatients with ADHD (84%) than in those without it (40%). They also found that ADHD was associated with higher PTSD symptom severity scores.
This study is only the second to assess the relationship between ADHD and PTSD in AUD inpatients and the results of both studies were similar.12
The high representation of PTSD in the sample (compared with other studies on the relationship between PTSD, ADHD, and AUD) could possibly be attributed to the backgrounds of the patients, the researchers said. Many of them had law enforcement and military backgrounds. Bias can also result from self-administered questionnaires and the increased knowledge of trauma-related disorders in patients with AUD.
Also of significance, ADHD patients reported exposure to a higher number of traumatic events, especially physical and sexual aggression and life-threatening events. This could be related to the association between ADHD and an increased risk of accidents, exposure to violence, and sexual abuse and may also be related to the increased risk of developing PTSD.13,14,15
The study does not shed light on whether ADHD symptoms precede those of PTSD or the reverse. Nor does it explain how PTSD during childhood might precede ADHD and later lead to AUD.
Another limitation of the study — the lack of assessment of other psychiatric disorders — was also acknowledged by the researchers. They suggest future studies look at a sample of individuals with less severe AUD (outpatients and primary care patients, for example) to determine whether their results can be generalized to individuals with AUD.
1 Antshel K M, Kaul P, Biederman J, Spencer T J, Hier B O, Hendricks K, Faraone S V. (2013). Posttraumatic stress disorder in adult attention-deficit/hyperactivity disorder: Clinical features and familial transmission. The Journal of Clinical Psychiatry, 74(3), e197–e204. https://doi.org/10.4088/JCP.12m07698
2Blanco C, Xu Y, Brady K, Pérez-Fuentes G, Okuda M, Wang S. (2013). Comorbidity of posttraumatic stress disorder with alcohol dependence among US adults: Results from the National Epidemiological Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence, 132(3), 630–638. https://doi.org/10.1016/j.drugalcdep.2013.04.016
3 Khoury L, Tang Y L, Bradley B, Cubells J F, Ressler K J. (2010). Substance use, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. Depression and Anxiety, 27(12), 1077–1086. https://doi.org/10.1002/da.20751
4 Norman S B, Haller M, Hamblen J L, Southwick S M, Pietrzak, R H (2018). The burden of co-occurring alcohol use disorder and PTSD in U.S. military veterans: Comorbidities, functioning, and suicidality. Psychology of Addictive Behaviors, 32(2), 224–229. https://doi.org/10.1037/adb0000348
5 van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W, Smit, F, Crunelle C L, Swets M, Schoevers R A (2012). Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: A meta-analysis and meta-regression analysis. Drug and Alcohol Dependence, 122(1–2), 11–19. https://doi.org/10.1016/j.drugalcdep.2011.12.007
6 Bernardi S, Faraone S V, Cortese S, Kerridge B T, Pallanti S, Wang, S, Blanco C (2012). The lifetime impact of attention deficit hyperactivity disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Psychological Medicine, 42(4), 875–887. https://doi.org/10.1017/S003329171100153X
7 Daurio A M, Aston, S A, Schwandt M L et al. (2018). Impulsive personality traits mediate the relationship between adult attention-deficit/hyperactivity symptoms and alcohol dependence severity. Alcoholism, Clinical and Experimental Research, 42(1), 173–183. https://doi.org/10.1111/acer.13538
8Spencer A E, Faraone S V, Bogucki O E, Pope A L, et al (2016). Examining the association between posttraumatic stress disorder and attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. The Journal of Clinical Psychiatry, 77(1), 72–83. https://doi.org/10.4088/JCP.14r09479
9Biederman J, Petty C R, Spencer T J, Woodworth K Y, Bhide P, Zhu J, Faraone S V (2014). Is ADHD a risk for posttraumatic stress disorder (PTSD)? Results from a large longitudinal study of referred children with and without ADHD. The World Journal of Biological Psychiatry, 15(1), 49–55. https://doi.org/10.3109/15622975.2012.756585
10 Dakwar E, Mahony A, Pavlicova M, Glass A, et al (2012). The utility of attention-deficit/hyperactivity disorder screening instruments in individuals seeking treatment for substance use disorders. The Journal of Clinical Psychiatry, 73(11), e1372–e1378. https://doi.org/10.4088/JCP.12m07895
11 Caci H M, Bouchez J, Baylé F J (2010). An aid for diagnosing attention-deficit/hyperactivity disorder at adulthood: Psychometric properties of the French versions of two Wender Utah Rating Scales (WURS-25 and WURS-K). Comprehensive Psychiatry, 51(3), 325–331. https://doi.org/10.1016/j.comppsych.2009.05.006
12Evren C, Umut G, Bozkurt M, Evren B, Agachanli R (2016). Mediating role of childhood emotional abuse on the relationship between severity of ADHD and PTSD symptoms in a sample of male inpatients with alcohol use disorder. Psychiatry Research, 239, 320–324. https://doi.org/10.1016/j.psychres.2016.03.049
13Schilpzand E J, Sciberras E, Alisic E, et al (2018). Trauma exposure in children with and without ADHD: Prevalence and functional impairment in a community-based study of 6-8-year-old Australian children. European Child & Adolescent Psychiatry, 27(6), 811–819. https://doi.org/10.1007/s00787-017-1067-y
14Konstenius M, Leifman A, van Emmerik-van Oortmerssen K, van de Glind G, Franck J, Moggi F et al (2017). Childhood trauma exposure in substance use disorder patients with and without ADHD. Addictive Behaviors, 65, 118–124. https://doi.org/10.1016/j.addbeh.2016.10.016
15Reinhardt M C, Reinhardt C A U (2013). Attention deficit-hyperactivity disorder, comorbidities, and risk situations. Jornal de Pediatria, 89(2), 124–130. https://doi.org/10.1016/j.jped.2013.03.015