PTSD, Substance Dependence and Stellate Ganglion Block (SGB): a case report in autonomic reset
Case Study Series
Patient Case Report • PTSD • Substance Dependence • Stellate Ganglion Block
Breaking the cycle: when PTSD drives addiction and how resetting the nervous system helped
How a Stellate Ganglion Block helped one man separate his trauma symptoms from his substance relapse urges — and protect three years of hard-won sobriety
3 yrs
Abstinence maintained
~80%
Reduction in autonomic surges
4 wks
To meaningful improvement
✓
Sobriety protected
Marcus — Late 30s
Self-employed content designer • Complex PTSD • History of alcohol and drug dependence • Self-pay patient
PTSD & autonomic dysregulation
Hypervigilance & hyperarousal
Substance dependence history
Significant improvement post-SGB
The Presentation
A man carrying trauma — and fighting to keep his sobriety with it
Marcus, a self-employed man in his late thirties, arrived at PainSpa carrying two significant burdens simultaneously: a deeply embedded pattern of PTSD symptoms rooted in past sexual trauma, and a hard-won sobriety that he feared he was losing his grip on. He had been abstinent from both alcohol and drugs for approximately three years — an achievement that required considerable daily effort — but the recent and sharp escalation of his PTSD symptoms had placed that sobriety under serious threat.
The pattern was distressingly clear to him. Whenever his PTSD symptoms flared — the surge of hyperarousal, the tightening in his chest, the sense of losing control — so too would the overwhelming urge to reach for substances. Alcohol and drugs had been his coping mechanism for years before he achieved sobriety, and now, as the alarm system of his nervous system fired with increasing frequency, those old pathways were pulling at him again. He described periods of feeling completely unable to determine what was safe, leading to a loss of control that had historically driven his substance use. Although he had not relapsed, he was acutely aware that he was living closer to that edge than at any point in the previous three years.
He had been managing relatively well until approximately four to six months before this consultation, when his PTSD symptoms began to recur and escalate markedly. He was already engaged with psychiatric services and attending EMDR therapy online every three weeks, with plans for more intensive work. He had also tried breathing techniques, self-regulation strategies and acupuncture, all with limited or temporary benefit. He came to PainSpa specifically to explore the role of Stellate Ganglion Block (SGB) as an adjunctive treatment — a procedure he had researched in depth and about which he had also listened to Dr Krishna’s audiobook, Resetting the Alarm: PTSD, The Nervous System and the Role of Stellate Ganglion Block.
Clinical Background
Why PTSD and substance relapse are so frequently intertwined
The connection between PTSD and substance use disorders is well recognised clinically, though it remains underappreciated in treatment settings. For many people, alcohol and drugs are not a primary addiction but a pharmacological strategy for managing an unbearable internal state. When the sympathetic nervous system is chronically dysregulated — as it is in PTSD — it creates a persistent state of biological alarm. The body is flooded with stress hormones, the threat detection system fires on hair trigger, and the experience of simply existing becomes exhausting and overwhelming.
In this context, substances offer rapid, reliable relief. Alcohol blunts the alarm. Drugs dull the hyperarousal. For someone with PTSD, using substances is not irrational — it is, in the short term, effective. The problem is that it creates dependency, and that dependency becomes tightly conditioned to the autonomic surges of PTSD. The two become neurologically linked: PTSD flare triggers craving, craving triggers use, and use temporarily suppresses the PTSD — until it returns, often worse. Breaking this cycle requires addressing both strands simultaneously.
The neurobiology of PTSD-driven substance relapse
Sympathetic nervous system
Chronically overactive in PTSD. The stellate ganglion acts as a key relay for sympathetic signalling. Dysregulation here drives the hyperarousal, chest tightness and surge-like sensations that characterise PTSD and trigger craving.
Conditioned relapse pathways
When substance use is repeatedly paired with autonomic surges, the brain learns to crave substances in response to those surges. Reducing the surges via SGB may therefore reduce the conditioned craving response alongside it.
The role of SGB
By temporarily blocking sympathetic overactivity at the stellate ganglion, SGB aims to reset the autonomic baseline. A calmer nervous system generates fewer and less intense surges — and therefore fewer and less intense relapse urges.
The therapeutic window
Reduction in autonomic hyperactivity following SGB creates a window in which psychotherapy — particularly trauma-focused EMDR — can be engaged with more effectively, addressing the underlying trauma that drives both the PTSD and the substance vulnerability.
Symptom Assessment
A comprehensive PTSD symptom picture across all major domains
Marcus presented with a classic and wide-ranging cluster of PTSD symptoms, clearly linked to his history of past sexual trauma. His PTSD Checklist responses confirmed significant symptom burden spanning all major domains — a pattern consistent with moderate to severe PTSD symptomatology. Crucially, each domain of symptoms also carried with it an increased risk of substance relapse, as the dysregulated nervous system repeatedly sought relief.
Re-experiencing
Intrusive symptoms
Intrusive memories and emotional distress when recalling past trauma • Disturbing dreams and nightmares • Flashback-like re-experiencing of traumatic events
Avoidance
Avoidance behaviours
Marked avoidance of crowds and noisy environments • Avoidance of thoughts related to past trauma • Social withdrawal and difficulty with interpersonal interactions
Hyperarousal
Autonomic overactivity
Persistent hypervigilance — constant scanning for danger • Exaggerated startle response • Feeling ‘wired but tired’ and unable to relax • Chest tightness when triggered
Mood & cognition
Emotional & cognitive effects
Episodes of paranoia • Brain fog and impaired concentration • Emotional dysregulation and reduced sense of safety • Significant sleep disturbance affecting daily functioning
The defining clinical feature: PTSD symptoms directly triggering substance relapse urges
Each time Marcus experienced a PTSD symptom surge — particularly the autonomic episodes of chest tightness, loss of control and hyperarousal — the urge to return to alcohol and drugs intensified. Three years of sobriety were being put under pressure not by choice, but by the neurobiological consequences of unresolved trauma. Addressing the autonomic dysregulation underpinning his PTSD was therefore directly connected to protecting his recovery from addiction.
The Treatment Journey
A stepwise, carefully considered approach to a complex case
Dr Krishna’s approach to Marcus reflected the complexity of his presentation: a detailed assessment that took account of both his PTSD and his substance dependence history, transparent and realistic discussion of what SGB could and could not offer, and a clear management plan that positioned the intervention as one component within a broader treatment framework.
Initial Consultation
Comprehensive assessment and clinical formulation
Dr Krishna conducted a detailed consultation, taking a thorough history of Marcus’s PTSD symptoms, trauma background, substance dependence history, and previous treatment experiences. Marcus had already listened to Dr Krishna’s audiobook Resetting the Alarm, giving him a strong grounding in the neurobiology of PTSD and how SGB works. Dr Krishna assessed his presentation as consistent with moderate to severe PTSD with prominent sympathetic nervous system dysregulation, and identified the direct link between his autonomic hyperarousal and his substance relapse vulnerability as a central clinical concern.
Expectation-Setting
Honest discussion of what SGB can and cannot achieve
Dr Krishna was careful to frame SGB realistically. He explained that approximately 40–50% of patients may not experience meaningful benefit, that some achieve only partial improvement, and that the duration of any benefit is variable. He was clear that SGB does not address the underlying trauma and that psychotherapy — particularly EMDR — remains the cornerstone of long-term PTSD management. In the context of Marcus’s substance history, he also discussed SGB as a potential aid to sobriety protection by reducing the autonomic surges that were driving his relapse urges.
Procedure
Bilateral Stellate Ganglion Block under real-time ultrasound guidance
Marcus attended the Willow Surgery, Downend, Bristol, for his procedures. The right-sided SGB was performed first, followed by the left-sided injection 24 hours later. The superior cervical ganglion was also targeted on both occasions. All injections were performed under real-time ultrasound guidance. On both occasions, Marcus developed rapid Horner’s Syndrome — the expected clinical sign of a successful block, resolving within 24 hours as anticipated and as had been explained pre-procedure. No anticoagulation was in use and there were no relevant allergies.
Four-Week Follow-Up (Videolink)
Significant and wide-ranging improvement confirmed
At follow-up approximately four weeks post-procedure, Marcus reported a clinically significant improvement across both his PTSD symptoms and, critically, his substance relapse urges. He described an approximately 80% initial reduction in the autonomic surges that had previously been so powerful. The chest tightness, the sense of overwhelm and loss of control — the very triggers that had historically driven him toward substances — had dramatically reduced in intensity. He felt calmer, more in control, and less easily overwhelmed. He now had a reference point for what reduced symptoms actually felt like.
The PainSpa Approach
Four pillars of PTSD and addiction management at PainSpa
Managing PTSD in the context of substance dependence requires a framework that addresses both the neurobiological and psychological dimensions of the patient’s experience. Dr Krishna’s approach is grounded in a structured, comprehensive model that positions SGB as an adjunct — not a replacement — for the psychological work that drives lasting recovery.
1. Deep clinical assessment
A thorough evaluation of all contributing factors — including the relationship between autonomic dysregulation, PTSD symptoms, and substance relapse vulnerability — before any intervention is considered.
2. Precision autonomic intervention
Bilateral SGB under real-time ultrasound guidance — targeting the overactive sympathetic signalling that drives both PTSD hyperarousal and, in patients with a dependence history, the associated craving response.
3. Transparent expectation-setting
Honest, detailed discussion of what SGB can and cannot achieve — including that benefit is not guaranteed, duration is variable, and trauma-focused psychotherapy remains essential.
4. Pathway to psychotherapy
SGB creates a reduced-arousal window in which EMDR and other trauma-focused therapies can be engaged with more effectively — particularly important where PTSD has previously made sustained therapeutic engagement difficult.
For patients with both PTSD and a history of substance dependence, the stakes could not be higher. When every autonomic surge is also a relapse risk, reducing those surges is not just about comfort — it is about protecting years of recovery. That is a powerful clinical rationale for exploring SGB in this patient group.
Dr Murli Krishna — Consultant in Pain Medicine, PainSpa
Outcome
What changed for Marcus at four weeks
Approximately four weeks following his bilateral Stellate Ganglion Blocks, Marcus reported a clinically meaningful and wide-ranging improvement — spanning his core PTSD symptoms, his emotional regulation, and — most significantly — the substance relapse urges that had placed his sobriety under sustained pressure.
Key improvements reported at four-week follow-up
● Approximately 80% reduction in autonomic hyper-reactivity — the chest tightness and surge-like sensations that had previously been overwhelming were dramatically reduced, with some mild return but still substantially improved from baseline
● Significant reduction in substance relapse urges — the previously overwhelming compulsion to return to alcohol and drugs had markedly improved; Marcus described a new, clear sense of control and separation from these impulses
● Improved emotional regulation — feeling calmer, less reactive, and better able to process situations proportionately without escalation
● Marked reduction in hypervigilance and exaggerated startle response — including a notably reduced reaction to stimuli that would previously have provoked a strong physiological response
● Improved cognitive control over triggers — better able to interrupt triggering thoughts and behaviours using grounding and sensory techniques
● Improved physiological resilience — greater capacity to tolerate stressors without escalation or emotional dysregulation
● A new and therapeutically important reference point: Marcus now knew what reduced symptoms felt like — a key psychological shift in PTSD management
Some partial return of symptoms was noted at four weeks, though at a substantially lower intensity than the pre-treatment baseline. Mild anticipatory anxiety about potential symptom relapse was reported, though this was not functionally impairing. Mild tinnitus of uncertain significance was noted and will be monitored.
Dr Krishna was particularly encouraged by the reduction in substance relapse urges. The fact that three years of sobriety were preserved through a period of acute PTSD escalation, supported in part by the autonomic modulation achieved through SGB, is a meaningful and important outcome.
Looking Ahead
The next steps in Marcus’s recovery
The SGB procedures have achieved their primary goal: a meaningful reduction in autonomic overactivity, a quietening of the relapse-driving surges, and the creation of a therapeutic window in which Marcus is better placed to engage with intensive trauma-focused psychotherapy.
Recommended ongoing management plan
PriorityIntensive EMDR therapy — planned and well-timed given Marcus’s current improved state. There is emerging evidence that patients who respond to SGB may engage more effectively with trauma-focused therapy post-procedure. This is the cornerstone of long-term PTSD and sobriety management.
OngoingContinued engagement with psychiatric services and the community mental health team, maintaining the multidisciplinary framework that has supported Marcus’s recovery so far.
MonitorOngoing self-monitoring of both PTSD symptoms and substance relapse urges, with attention to whether the two continue to track together — a clinically useful marker for the duration of SGB benefit.
If neededRepeat SGB can be considered if symptoms recur. Patients who respond well to an initial course often respond again to repeat treatment, though this is not guaranteed.
OpenAn open follow-up appointment remains available under Dr Krishna’s care. Marcus can re-engage with specialist input at any point as his recovery progresses.
Your Specialist
About Dr Murli Krishna
Dr Murli Krishna
Consultant in Pain Medicine — PainSpa
MBBS • FRCA • FFPMRCA • Fellow of the Faculty of Pain Medicine
Dr Krishna is a highly experienced Consultant in Pain Medicine practising at PainSpa’s clinics in Bristol, including Willow Surgery in Downend and the Chesterfield Nuffield Hospital in Clifton. He specialises in the diagnosis and interventional management of complex chronic pain and autonomic conditions, with a growing practice in Stellate Ganglion Block for PTSD and related disorders.
His approach to patients with complex presentations — including those where PTSD intersects with substance dependence — is grounded in a thorough understanding of the neurobiological mechanisms driving the patient’s experience. He situates every intervention within a comprehensive management framework that keeps psychological recovery at its core.
Dr Krishna consults in person and via telephone or videolink. Patients interested in exploring Stellate Ganglion Block for PTSD — including those with a history of substance dependence — are encouraged to contact PainSpa to arrange an initial assessment consultation.
Please note: This case study is published for educational and informational purposes. All patient-identifying details — including name, age, occupation, and location — have been changed or generalised to protect patient confidentiality. Patient consent to publish has been obtained. Individual results from SGB treatment vary considerably; the procedure does not guarantee improvement and is not effective for all patients. SGB is not a replacement for evidence-based psychological therapies for PTSD, which remain the primary treatment, and it is not a treatment for substance dependence. This does not constitute medical advice. Please contact PainSpa to discuss your individual circumstances. For complaints or queries, please write to clinic@painspa.co.uk.
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