Risk pathways among traumatic stress, posttraumatic stress disorder symptoms, and alcohol and drug problems: a test of four hypotheses

The development and initial validation of the Trauma-Related Alcohol Use Coping Measure (TRAC)

OBJECTIVE

Posttraumatic stress disorder (PTSD) symptoms and alcohol use commonly co-occur and present a prevalent clinical comorbidity. The self-medication/coping model has been applied most consistently to understand the PTSD-alcohol use association. However, there is a relative paucity of self-report measures designed to assess motivations for alcohol use, specifically for coping with PTSD symptoms. The goals of the present study were to develop and validate a measure that assesses the use of alcohol to cope with specific facets of PTSD symptomatology across two independent samples.

METHOD

Two samples were evaluated: a university-based sample (N = 617; 77.0% women; Mage = 22.3; SD = 5.20) composed of racially diverse trauma-exposed students and a nationally representative sample (N = 510; 52.5% women; Mage = 39.5; SD = 10.9) of trauma-exposed adults who endorsed PTSD symptoms and past-year hazardous drinking. Both samples completed identical online questionnaire batteries. A Trauma-Related Alcohol Use Coping (TRAC) measure was developed and validated across both samples.

RESULTS

Confirmatory factor analysis was used to support the latent, hierarchical structure of the TRAC measure (total score; coping with intrusion, avoidance, negative alterations in cognitions and mood, and arousal/reactivity symptoms) and supported an 18-item version of the TRAC measure (university-based sample [N = 617]: RMSEA = 0.047, 90% CI [.04, .05]; SRMR = 0.043; CFI = 0.95; TLI = 0.95; nationally representative sample [N = 510]: RMSEA = 0.045, 90% CI [.04, .05]; SRMR = 0.021; CFI = 0.98; TLI = 0.97). The TRAC measure demonstrated excellent internal consistency, convergent, and discriminant validity with well-established measures of mental health, known-groups validity, and incremental validity relative to non-PTSD coping-motivated drinking.

CONCLUSIONS

Overall, the TRAC measure can be used to assess the extent to which alcohol use is related to coping with PTSD symptoms. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The role of recurrent trauma on post-traumatic stress disorder symptoms and substance use among trauma exposed youth

Comorbidity between post-traumatic stress disorder (PTSD) and substance use disorder may be explained by a prospective trauma risk conferred by both conditions. The current study modeled concurrent and prospective associations of trauma, PTSD symptoms, and substance use (SU) behavior among trauma exposed youth (ages 8-20). Clinical interviews assessed trauma exposure, PTSD symptom severity, and SU behavior at baseline and at six- and 12-month follow up study visits (N = 2,069). Structural equation models assessed the associations of trauma, PTSD symptoms, and SU behavior. Lifetime trauma was associated with more severe PTSD symptoms and SU behaviors, whereas trauma exposure during the study was only associated with PTSD symptoms. PTSD symptom severity was prospectively associated with trauma exposure. PTSD symptom severity and SU behavior at follow-up study visits were prospectively associated. These results highlight the dynamic interplay between trauma, PTSD symptoms, and SU behavior during youth, a developmental period during which complex psychiatric presentations can have longstanding consequences for health.

Innovative outpatient treatment for veterans and service members and their family members

In 2009, Massachusetts General Hospital and the Red Sox Foundation launched Home Base, a nonprofit dedicated to providing care to veterans, service members, and their loved ones who struggle with the invisible wounds of war free of charge. Significant needs exist for mental health services in each of these populations, and a need for innovative approaches to address shortcomings in existing treatment models. Three inventive components of our programming are highlighted herein: a Veteran Outreach Team, which helps to engage patients in care, programming, and services specifically for family members, and an intensive outpatient substance use treatment program. More than 4,000 patients, 3,031 veterans and service members, and 1,025 family members have engaged in treatment at Home Base. Patients were asked to complete post-treatment self-measures, including a satisfaction questionnaire via an electronic data collection system. The vast majority of individuals who engaged in our treatment model were satisfied with the care they received (>92%) and would refer their peers to the Home Base program (>75%). Data from 78 individuals who completed the dual diagnosis services demonstrated large effect sizes in reductions in alcohol use and comorbid mental health symptoms. These data suggest that novel components to the standard outpatient mental health model might provide substantive benefits for the patients served. While internal data is prone to a lack of generalizability, these additional offerings help ameliorate patients' expressed shortcomings with existing models; present literature that describes the benefits that these additions provide is also reviewed. The lessons learned and limitations are discussed.

Perceived advantages and disadvantages of substance use in a dual diagnosis population with severe mental disorders and severe substance use disorder. Considering the self-medication hypothesis

AIM

Based on a large cohort of dual diagnosis patients, the aim of this study was to quantify the patient-perceived problems and advantages of their substance use and relate the quantity of problems to the substance type and psychiatric diagnosis.

MATERIAL

Data comes from a naturalistic cohort admitted to an in-patient facility in Denmark specialized in integrated dual diagnosis treatment. We included 1076 patients at their first admission to the facility from 2010 to 2017. Participants completed 607 DrugCheck and 130 DUDIT-E questionnaires.

METHOD

we analyzed the questionnaires and included admission diagnosis by use of t-test and ANOVA to depict the patterns in substance use in relation to psychiatric diagnosis.

RESULTS

The three most common substance related problems according to the DrugCheck questionnaire were: feeling depressed, financial problems, and losing interest in daily activities. From DUDIT-E, the highest-ranking negative substance related effects were financial ruin, deterioration of health, and problems at work. Effects on social life relationships were also evident with more than 40% of participants. The top three positive substance related effects reported were relaxation, improved sleep, and control over negative emotions. The number of problems listed varied significantly with the type of preferred substance. Patients using pain medication, sedatives, central stimulants, and alcohol reported most problems. Diagnosis did not differentiate the problems experienced. Results partially support the broad self-medication hypothesis for patients with severe mental illness, but also points out that patients are well aware of negative effects.

Do traumatic events and substance use co-occur during adolescence? Testing three causal etiologic hypotheses

BACKGROUND

Why do potentially traumatic events (PTEs) and substance use (SU) so commonly co-occur during adolescence? Causal hypotheses developed from the study of posttraumatic stress disorder (PTSD) and substance use disorder (SUD) among adults have not yet been subject to rigorous theoretical analysis or empirical tests among adolescents with the precursors to these disorders: PTEs and SU. Establishing causality demands accounting for various factors (e.g. genetics, parent education, race/ethnicity) that distinguish youth endorsing PTEs and SU from those who do not, a step often overlooked in previous research.

METHODS

We leveraged nationwide data from a sociodemographically diverse sample of youth (N = 11,468) in the Adolescent Brain and Cognitive Development Study. PTEs and substance use prevalence were assessed annually. To account for the many pre-existing differences between youth with and without PTE/SU (i.e. confounding bias) and provide rigorous tests of causal hypotheses, we linked within-person changes in PTEs and SU (alcohol, cannabis, nicotine) across repeated measurements and adjusted for time-varying factors (e.g. age, internalizing symptoms, externalizing symptoms, and friends' use of substances).

RESULTS

Before adjusting for confounding using within-person modeling, PTEs and SU exhibited significant concurrent associations (βs = .46-1.26, ps < .05) and PTEs prospectively predicted greater SU (βs = .55-1.43, ps < .05) but not vice versa. After adjustment for confounding, the PTEs exhibited significant concurrent associations for alcohol (βs = .14-.23, ps < .05) and nicotine (βs = .16, ps < .05) but not cannabis (βs = -.01, ps > .05) and PTEs prospectively predicted greater SU (βs = .28-.55, ps > .05) but not vice versa.

CONCLUSIONS

When tested rigorously in a nationwide sample of adolescents, we find support for a model in which PTEs are followed by SU but not for a model in which SU is followed by PTEs. Explanations for why PTSD and SUD co-occur in adults may need further theoretical analysis and adaptation before extension to adolescents.

A network analysis of Hurricane Maria-related traumatic stress and substance use among Puerto Rican youth

Youth exposed to natural disasters are at risk of developing trauma-related symptoms as well as engaging in substance use. Although previous research has established associations between disaster-related stressors and substance use in youth, less has focused on how symptoms of posttraumatic stress disorder (PTSD) may underpin this association. The current study used network analysis to identify specific PTSD symptoms associated with substance use following a natural disaster. Participants were 91,732 youths (Grades 3-12) from across Puerto Rico who completed a needs assessment 5-9 months after Hurricane Maria made landfall in September 2017. We examined associations between PTSD symptoms and substance use, identified clusters of symptoms and bridges between them, and explored age- and binary gender-related differences in associations between specific PTSD symptoms and substance use. Analyses identified two symptom communities: (a) arousal and reactivity, negative alterations in cognition and mood, and substance use, and (b) avoidance and intrusion. Broader findings suggested that substance use was most strongly associated with PTSD-related irritability and angry outbursts among youths. Surrounding nodes explained only 4.1% of the variance in substance use, but this was higher among youths who reported not having a supportive adult, R2 = 8.5; friend, R2 = 7.9; or teacher/counselor, R2 = 7.7, in their life. The bridge symptoms of sleep disruption and physiological reactivity were identified as potentially critical intervention targets for disrupting PTSD symptom networks after a natural disaster. Implications for triaged mental health care following natural disasters and directions for future research are discussed.

Web-Based Screening, Brief Intervention, and Referral to Treatment for Traumatic Stress and Alcohol Misuse Among Survivors of Sexual Assault and Intimate Partner Violence: Usability and Acceptability Study

BACKGROUND

Recent survivors of intimate partner violence (IPV) and sexual assault (SA) are at a high risk for traumatic stress and alcohol misuse. IPV and SA survivors face barriers to services for traumatic stress and alcohol misuse and have low service utilization rates. One way to increase access to services for this population is the use of web-based screening, brief intervention, and referral to treatment (SBIRT), an evidence-informed approach for early identification of traumatic stress and alcohol and drug misuse and connecting individuals to treatment.

OBJECTIVE

This study aims to assess the usability and acceptability of a web-based SBIRT called CHAT (Choices For Your Health After Trauma) tailored to address traumatic stress and alcohol misuse following past-year IPV, SA, or both.

METHODS

Phase 1 involved gathering feedback about usability and acceptability from focus groups with victim service professionals (22/52, 42%) and interviews with past-year survivors of IPV, SA, or both (13/52, 25%). Phase 2 involved gathering feedback about the acceptability of an adapted version of CHAT in an additional sample of recent survivors (17/52, 33%). Survey data on history of IPV and SA, posttraumatic stress disorder symptoms, alcohol and drug use, and service use were collected from survivors in both phases to characterize the samples. Qualitative content and thematic analyses of the interviews and focus group data were conducted using a coding template analysis comprising 6 a priori themes (usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance).

RESULTS

Six themes emerged during the focus groups and interviews related to CHAT: usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance. Phase 1 providers and survivors viewed CHAT as acceptable, easy to understand, and helpful. Participants reported that the intervention could facilitate higher engagement in this population as the web-based modality is anonymous, easily accessible, and brief. Participants offered helpful suggestions for improving CHAT by updating images, increasing content personalization, reducing text, and making users aware that the intervention is confidential. The recommendations of phase 1 participants were incorporated into CHAT. Phase 2 survivors viewed the revised intervention and found it highly acceptable (mean 4.1 out of 5, SD 1.29). A total of 4 themes encapsulated participant's favorite aspects of CHAT: (1) content and features, (2) accessible and easy to use, (3) education, and (4) personalization. Six survivors denied disliking any aspect. The themes on recommended changes included content and features, brevity, personalization, and language access. Participants provided dissemination recommendations.

CONCLUSIONS

Overall, CHAT was acceptable among victim service professionals and survivors. Positive reactions to CHAT show promise for future research investigating the efficacy and potential benefit of CHAT when integrated into services for people with traumatic stress and alcohol misuse after recent IPV and SA.

Race-based Traumatic Stress Predicts Risky Drinking, Over and Above Negative Affect, and Non-race-related Trauma Symptoms in Racial/Ethnic Minority Female College Students

OBJECTIVES

Alcohol misuse remains a major concern in college student populations and rates of risky and problematic drinking are specifically on the rise for women. One important factor that has been shown to be positively associated with substance use/misuse for women from historically marginalized or minoritized racial/ethnic backgrounds is exposure to racial discrimination and possible resulting traumatic stress reactions. Questions remain about the relationship between race-based traumatic stress and risky drinking particularly among diverse female college students who are at greater risk due to their marginalized status in their racial/ethnic and gender groups.

DESIGN

The current study examined race-based traumatic stress as a unique predictor of risky drinking when controlling for negative affectivity and general trauma symptoms, additional risk factors for risky drinking in women.

RESULTS

Hierarchical linear regressions revealed that race-based traumatic stress made a significant and unique contribution to the amount of variance in risky drinking, above negative affectivity, and general trauma symptoms.

CONCLUSION

These findings highlight the importance of considering experiences of racism as risk factors in substance use prevention and intervention, specifically for female college students from marginalized or minoritized racial/ethnic backgrounds.

Associations of alcohol and cannabis use with change in posttraumatic stress disorder and depression symptoms over time in recently trauma-exposed individuals

BACKGROUND

Several hypotheses may explain the association between substance use, posttraumatic stress disorder (PTSD), and depression. However, few studies have utilized a large multisite dataset to understand this complex relationship. Our study assessed the relationship between alcohol and cannabis use trajectories and PTSD and depression symptoms across 3 months in recently trauma-exposed civilians.

METHODS

In total, 1618 (1037 female) participants provided self-report data on past 30-day alcohol and cannabis use and PTSD and depression symptoms during their emergency department (baseline) visit. We reassessed participant's substance use and clinical symptoms 2, 8, and 12 weeks posttrauma. Latent class mixture modeling determined alcohol and cannabis use trajectories in the sample. Changes in PTSD and depression symptoms were assessed across alcohol and cannabis use trajectories via a mixed-model repeated-measures analysis of variance.

RESULTS

Three trajectory classes (low, high, increasing use) provided the best model fit for alcohol and cannabis use. The low alcohol use class exhibited lower PTSD symptoms at baseline than the high use class; the low cannabis use class exhibited lower PTSD and depression symptoms at baseline than the high and increasing use classes; these symptoms greatly increased at week 8 and declined at week 12. Participants who already use alcohol and cannabis exhibited greater PTSD and depression symptoms at baseline that increased at week 8 with a decrease in symptoms at week 12.

CONCLUSIONS

Our findings suggest that alcohol and cannabis use trajectories are associated with the intensity of posttrauma psychopathology. These findings could potentially inform the timing of therapeutic strategies.

Sex and Gender Differences in Co-Occurring Alcohol Use Disorder and PTSD

Purpose of Review

Research demonstrates a strong association between alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD). However, less is known about sex- and gender-based differences among individuals with AUD + PTSD. This narrative review examines recent literature in this area and aims to be a reference for future research endeavors.

Recent Findings

Extant literature shows that intertwining biological systems increase females' risk of developing PTSD and experiencing more adverse effects from AUD compared to males. Sex-based physiological differences further interact with gendered sociocultural environments to influence the risk of AUD + PTSD. Emerging research suggests potential gender-specific pathways between PTSD, coping, and AUD which may inform prevention and treatment. However, barriers to care are often gender-specific and tailored approaches are needed to improve reach and uptake.

Summary

Additional research is needed to examine intersectional and contextual factors that synergistically influence sex/gender differences in AUD + PTSD, particularly beyond cisgender identities, and mechanisms of action.

Childhood maltreatment and internalizing/externalizing disorders in trauma-exposed adolescents: Does posttraumatic stress disorder (PTSD) severity have a mediating role?

Childhood maltreatment is associated with wide-ranging psychopathology at all stages of life. In the current study, we investigated whether posttraumatic stress disorder (PTSD) severity mediated the association between childhood maltreatment and internalizing and externalizing disorders among 262 South African trauma-exposed adolescents (aged 12-18 years). Childhood maltreatment and PTSD symptom severity were assessed using the Childhood Trauma Questionnaire and the Child PTSD Checklist, respectively. Psychiatric disorders were assessed utilizing the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version and were grouped into internalizing or externalizing disorders. Hierarchal logistic regression was used to assess the association of childhood maltreatment subtype with internalizing and externalizing disorders, controlling for age and gender, with PTSD symptom severity added to the final model. We found that sexual abuse was significantly associated with internalizing disorders, although this effect was no longer significant when PTSD was added to the model demonstrating that PTSD mediated the association between sexual abuse and internalizing disorders. Physical abuse, but not PTSD, was associated with externalizing disorders. Physical abuse, emotional neglect, and PTSD were associated with comorbid internalizing and externalizing disorders. These findings have implications for intervention and prevention strategies targeted at trauma-exposed adolescents with a history of childhood maltreatment.

Post-traumatic stress disorder and drug use disorder: examination of aetiological models in a Swedish population-based cohort

Background: There are two primary phenotypic models of comorbidity between post-traumatic stress disorder (PTSD) and drug use disorder (DUD), i.e. self-medication (PTSD precedes and causes DUD) and susceptibility (DUD precedes and causes PTSD). We sought to clarify the longitudinal relationship between PTSD and DUD, while examining sex differences.Method: We used approximately 23 years of longitudinal data from Swedish population registries to conduct two complementary statistical models: Cox proportional hazard models (N ≈ 1.5 million) and a cross-lagged panel model (N ≈ 3.8 million).Results: Cox proportional hazards models, adjusting for cohort and socioeconomic status, found strong evidence for the self-medication hypothesis, as PTSD predicted increased risk for DUD among both women [hazard ratio (HR) = 5.34, 95% confidence interval (CI) 5.18, 5.51] and men (HR = 3.65, 95% CI 3.54, 3.77), and moreover, that the PTSD to DUD association was significantly higher among women (interaction term 0.68, 95% CI 0.65, 0.71). The results of the susceptibility model were significant, but not as strong as the self-medication model. DUD predicted risk for PTSD among both women (HR = 2.43, 95% CI 2.38, 2.50) and men (HR = 2.55, 95% CI 2.50, 2.60), and HR was significantly higher in men (interaction term 1.05, 95% CI 1.02, 1.08). Investigating the pathways simultaneously in the cross-lagged model yielded support for both pathways of risk. The cross-paths instantiating the susceptibility model (0.10-0.22 in females, 0.12-0.19 in males) were mostly larger than those capturing the self-medication model (0.01-0.16 in females, 0.04-0.22 in males).Conclusions: We demonstrate that the relationship between PTSD and DUD is bidirectional, with evidence that future research should prioritize examining specific pathways of risk that may differ between men and women.

Factors Associated with High-Risk Substance Use in Persons Receiving Psychiatric Treatment for a Primary Trauma- and Stressor-Related Disorder Diagnosis

OBJECTIVE

Although mental health disorders and high-risk substance use frequently co-occur, they are typically investigated independently. Clinical trials focused on treatment for individuals with trauma- and stressor-related disorders often exclude individuals with high-risk substance use. Little is also known about the role of gender in the relationship between trauma- and stressor-related disorders and high-risk substance use. We examined the relationship between trauma- and stressor-related disorders, high-risk substance use, and gender.

METHODS

Using the Mental Health Client-Level Data dataset, we examined 15,772 adults receiving treatment in psychiatric hospitals in the United States from 2013 to 2019.

RESULTS

A logistic regression model showed that for men, relative to women, having multiple mental health diagnoses and having a serious mental illness or serious emotional disturbance was associated with greater odds of high-risk substance use.

CONCLUSIONS

This study underscores the value of comprehensive gender-centered treatment for people with trauma- and stressor-related disorders engaging in high-risk substance use.

Longitudinal Investigation of Bidirectional Relations Between Childhood Trauma and Emotion-Driven Impulsivity in the Adolescent Brain Cognitive Development Study

OBJECTIVE

Exposure to childhood trauma is associated with numerous adverse mental health consequences. Addressing important gaps in the existing research, the proposed study clarifies the longitudinal and bidirectional associations between childhood trauma and both negative and positive emotion-driven impulsivity.

METHOD

This study utilized a sample of 11,872 9- to 10-years-olds recruited from 21 research sites across the United States from the Adolescent Brain Cognitive Ddevelopment (ABCD) Study. Childhood trauma was assessed at one- and two-year follow-ups. Negative and positive urgency were assessed at baseline and two-year follow-up. Cross-lagged panel models evaluated the longitudinal and bidirectional associations between childhood trauma and both negative and positive emotion-driven impulsivity.

RESULTS

Findings showed that earlier childhood trauma was associated with higher levels of later negative (β = 0.133, p < .001) and positive (β = 0.125, p < .001) emotion-driven impulsivity. Further, higher levels of earlier positive (β = 0.033, p < .006), but not negative (β = 0.010, p = .405), emotion-driven impulsivity were associated with later childhood trauma. Finally, the strength of the relations between childhood trauma and emotion-driven impulsivity did not differ by sex (ΔX2 = 10.228, p > .05).

DISCUSSION

Identification of both negative and positive emotion-driven impulsivity among children exposed to trauma may serve as a point of intervention to reduce subsequent risk for deleterious health outcomes.

Racial trauma as a risk factor for risky alcohol use in diverse college students

Exposure to potentially traumatic race-based experiences poses a risk factor for risky drinking among college students from historically marginalized racial/ethnic backgrounds. Objective: The current study examined the relationship between both the level (severity) and pattern of race-based traumatic stress (RBTS) reactions and risky drinking. Participants: The current study sample was made up of 62 male (23.5%) and 202 female (76.5%) Latino/a/x, Black, and Asian college students attending a minority-serving institution. Methods: Study participants were asked to participate in an anonymous online survey. Results: A criterion profile analysis revealed that higher scores on RBTS reactions overall, and elevated scores on RBTS - avoidance, low self-esteem, and anger, specifically, were indicative of more risky drinking. Conclusions: These findings highlight a distinct pattern of RBTS scores that may predict a vulnerability to risky drinking and underscore the importance of racial trauma healing in alcohol use prevention and intervention efforts.

Biopsychosocial Model of Traumatic Stress Symptoms in Women Experiencing Homelessness: A Qualitative Descriptive Study

Trauma is nearly ubiquitous among women experiencing homelessness (WEH). WEH develop post-traumatic stress disorder (PTSD) at rates far exceeding the general population. The consequences of untreated PTSD can cascade, exacerbating existing physical, mental, and social health inequities, placing this population at risk for disproportionate biopsychosocial health adversity. Despite the outsized impact of PTSD, WEH are less likely to access or receive appropriate trauma-focused services. Understanding the unique and intersecting factors that contribute to the disproportionate PTSD toll on WEH may elucidate risk and protective factors, as well as possible intervention pathways to address the disparate trauma burden. This study employed a qualitative descriptive approach to develop understanding of the determinants of trauma risk, exposure, and outcomes among WEH. Semi-structured interviews were completed with 10 WEH, six shelter staff, four mental health professionals. Six deductively biopsychosocial model-derived themes were identified, alongside supporting categories. Themes/categories highlighted the role of biological, psychological, and socio-environmental determinants in shaping risk for and actualization of traumatic events and adverse outcomes. Trauma played an outsized role in shaping the health of WEH participants in this study, and the need for and interest in tailored trauma screening, treatment, psychoeducation options was highlighted. Recursive relationships between biopsychosocial determinants and trauma impact were identified. Participants emphasized population tailored trauma-focused interventions, specifically brief co-designed and community partner implemented interventions that address substance use behaviors, while leveraging the strengths of WEH. Addressing the marked trauma burden in WEH shows promise in promoting measurable biopsychosocial health improvements in this resilient yet overlooked population.

Role of positive emotion regulation strategies in the association between childhood trauma and posttraumatic stress disorder among trauma-exposed individuals who use substances

BACKGROUND

The co-occurrence of childhood trauma and posttraumatic stress disorder (PTSD) is highly prevalent and clinically significant. Existing research emphasizes the role of emotion regulation in the relation between childhood trauma and PTSD. Yet, research in this area has almost exclusively examined the influence of strategies aimed at regulating negative emotions, such as anger and sadness.

OBJECTIVE

To extend existing research, the current study examined underlying roles of strategies for regulating positive emotions (i.e., self- and emotion-focused positive rumination and positive dampening) in the association between childhood trauma severity and PTSD symptoms.

PARTICIPANTS AND SETTING

Participants were 320 trauma-exposed community individuals who reported past 30-day substance use (Mage = 35.78, 50.3% men, 81.6% white).

METHOD

Analyses examined whether childhood trauma severity was indirectly related to PTSD symptoms through self-focused positive rumination, emotion-focused positive rumination, and positive dampening.

RESULTS

Positive dampening, but not positive self- and emotion-focused positive rumination, indirectly explained associations between childhood trauma severity and PTSD symptoms (B = .17, SE = .03, 95% CI [.12, .24]).

CONCLUSIONS

These findings highlight the potential utility of targeting positive dampening in the treatment of PTSD symptoms among individuals who use substances with a history of childhood trauma.

PTSD Symptoms and Hazardous Drinking Indicators among Trauma-Exposed Sexual Minority Women during Heightened Societal Stress

Trauma-exposed sexual minority women (SMW) are at elevated risk of posttraumatic stress disorder (PTSD) and hazardous drinking compared to trauma-exposed heterosexual women. To understand whether these problems might be exacerbated during times of elevated societal stress, we collected data from a New York-based sample of trauma-exposed SMW between April 2020 and August 2020, a period of notable, compounding societal stressors, including: (a) living in or near one of the first epicenters of the coronavirus disease 2019 (COVID-19) epidemic in the United States and (b) living through multiple high-profile occurrences of racism-related police violence and subsequent racial unrest. SMW (n = 68) completed online self-report questionnaires related to trauma, PTSD symptoms, and alcohol use, and a subset (n = 29) completed semi-structured qualitative interviews. PsycINFO was searched with terms related to SMW, PTSD, and alcohol use to identify studies with samples of SMW from articles published within the last 10 years to which we could compare our sample; this produced nine studies. Welch's t-tests and Chi-square analyses revealed that SMW within our sample reported significantly higher PTSD symptom severity, probable PTSD, and hazardous drinking indicators (i.e., alcohol use disorder and heavy episodic drinking) between April 2020 and August 2020 compared to similar samples (i.e., trauma-exposed SMW and general samples of SMW) assessed previously. Qualitative reports also indicated that the societal stressors of 2020 contributed to mental and behavioral health concerns. These results underscore the need for integrated PTSD and alcohol use prevention and intervention efforts for trauma-exposed SMW during times of heightened societal stress.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.2006132 .

Parenting stress and competence among mothers of young children with substance use disorders: The roles of trauma and reflective functioning

Posttraumatic stress symptoms are prominent in the lives of parents of young children with substance use disorders (SUD). Parenting experiences, particularly stress and competence, impact parenting behaviors and concomitant child growth and development. Factors that promote positive experiences of parenting, such as parental reflective functioning (PRF), and protect the mother and child from negative outcomes are crucial to understand to develop effective therapeutic interventions. The current US study analyzed baseline data from a parenting intervention evaluation to examine how length of substance misuse, PRF, and trauma symptoms were associated with parenting stress and parenting sense of competence among mothers in treatment for SUDs. Measures included the Addiction Severity Index, PTSD Symptom Scale-Self Report, Parental Reflective Functioning Questionnaire, Parenting Stress Index/Short Form, and Parenting Sense of Competence Scale. The sample included 54 predominantly White mothers with SUDs who had young children. Two multivariate regression analyses found that (1) lower parental reflective functioning and higher posttraumatic stress symptoms were associated with higher parenting stress, and (2) only higher posttraumatic stress symptoms were associated with lower levels of parenting sense of competence. Findings underscore the importance of addressing trauma symptoms and PRF when aiming to improve parenting experiences for women with an SUD.

Comorbid posttraumatic stress disorder and alcohol use disorder in low- and middle-income countries: A narrative review

Much of the research on posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) has been conducted in high-income countries (HICs). However, PTSD and AUD commonly co-occur (PTSD + AUD) are both associated with high global burden of disease, and disproportionately impact those in low- and middle-income countries (LMICs). This narrative review attempts to synthesize the research on prevalence, impact, etiological models, and treatment of PTSD + AUD drawing from research conducted in HICs and discussing the research that has been conducted to date in LMICs. The review also discusses overall limitations in the field, including a lack of research on PTSD + AUD outside of HICs, issues with measurement of key constructs, and limitations in sampling strategies across comorbidity studies. Future directions are discussed, including a need for rigorous research studies conducted in LMICs that focus on both etiological mechanisms and on treatment approaches.

Does Effectiveness of a Brief Substance Use Treatment Depend on PTSD? An Evaluation of Motivational Enhancement Therapy for Active-Duty Army Personnel

OBJECTIVE

Posttraumatic stress disorder (PTSD) with comorbid substance use disorders (SUDs) has been associated with poorer treatment outcomes. The present study examined associations between provisional PTSD at baseline and 3 months with 6-month treatment outcomes from either a one-session motivational enhancement therapy (MET) or education intervention addressing substance use.

METHOD

Secondary analyses were conducted on a randomized clinical trial comparing a novel MET intervention to an educational intervention for Army personnel with SUD who were not engaged in SUD treatment (n = 242; 92.1% male). We compared three groups with complete data on baseline and 3-month provisional PTSD: individuals without provisional PTSD at baseline (n = 98), those with provisional PTSD remitted by 3 months (n = 42), and those with provisional PTSD unremitted at 3 months (n = 53) on alcohol use frequency, quantity, consequences, and related diagnoses.

RESULTS

Individuals with unremitted provisional PTSD were at increased risk for moderate/severe alcohol use disorder at 6 months relative to those without baseline provisional PTSD (odds ratio = 4.53, p = .007). The effect of MET on drinks per week at 6 months (controlling for baseline) differed with a significant effect of MET for individuals with remitted provisional PTSD (count ratio = 0.41, p = .005).

CONCLUSIONS

Both interventions were effective in reducing drinking even for those with provisional PTSD, although, compared with education, MET had slightly better effects on reducing drinking quantity for those with remitted PTSD. Findings suggest that PTSD remission may serve as an early prognostic indicator of long-term alcohol use changes, or alternatively, delivery of MET during heightened transitory distress may be most effective for reducing alcohol use.

Predictors of therapeutic alliance, treatment feedback, and clinical outcomes among African American women in treatment for co-occurring PTSD and SUD

INTRODUCTION

Black women are at heightened risk for trauma exposure, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), compared to White women and the general population. However, disparities in treatment engagement and retention persist, particularly for Black women with co-occurring PTSD+SUD. Although therapeutic alliance is an important predictor and mediator of treatment retention and outcomes, we know little about predictors of alliance and the mediating role of alliance for PTSD+SUD outcomes among Black women.

METHODS

This study utilized data previously collected for the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study. Participants were 88 Black/African American women (Mage = 41.90, SD = 7.72) participating in a clinical trial comparing Seeking Safety (a cognitive-behavioral intervention for PTSD+SUD) to Women's Health Education (control). This study includes participants from both arms. Measures included the Helping Alliance Questionnaire, Addiction Severity Index-Lite, and Clinician Administered PTSD Scale. Women in the intervention arm also completed the Seeking Safety Feedback Questionnaire.

RESULTS

Stepwise, hierarchical linear regressions indicated that years of education and previous alcohol/drug treatment attempts significantly predicted early alliance in the second week of therapy (β = 0.411, p = .021 and β = 0.383, p = .011, respectively), but not late alliance in the last week of therapy (ps > .794). Greater education and more treatment attempts were associated with higher early alliance. Alliance did not mediate relationships between these significant predictors and treatment outcomes (e.g., attendance, post-treatment PTSD and SUD symptoms) or treatment feedback in the Seeking Safety group.

CONCLUSIONS

Education and prior treatment attempts predicted early alliance among Black/African American women in PTSD+SUD group treatment, and higher education level was associated with poorer Seeking Safety feedback topic ratings. Educational level and treatment history should be considered during alliance building in therapeutic interventions with Black women. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education. This study provides insight into the relative impact of several important factors that influence early alliance among Black women with co-occurring PTSD+SUD.

Posttraumatic stress disorder, drinking to cope, and harmful alcohol use: A multivariate meta-analysis of the self-medication hypothesis

The association between posttraumatic stress disorder (PTSD) and harmful alcohol use has often been explained through the self-medication hypothesis via coping-related drinking motives. However, the magnitude of the indirect effect of PTSD on harmful alcohol use through coping motives is unclear. This study aggregated this indirect effect using a meta-analytic structural equation modeling approach and explored moderators that influenced the indirect effect. We identified articles from PsycINFO, PubMed/MEDLINE, and PROQUEST (through June 22, 2021) containing measures of (a) PTSD symptoms, (b) coping-related drinking, and (c) harmful alcohol use. Thirty-four studies yielding 69 effect sizes were included (mean N = 387.26 participants; median N = 303.5; range = 42-1,896; aggregate sample n = 15,128). Coping motives mediated the relation between PTSD and harmful alcohol use, accounting for 80% of the variance in the total effect. Moderating variables and evidence of publication bias were also found. Findings suggest that coping-related drinking is a strong mediator in the relation between PTSD and harmful alcohol use and that the strength of the indirect effect is meaningfully influenced by measurement approach, sample characteristics, and study design. Additional longitudinal and multivariate studies are needed to establish directionality and account for additional variance. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Interpersonal Violence, PTSD, and Substance Use Types among Women Receiving Substance Use Treatment

Objective: Many women receiving substance use treatment report histories of interpersonal violence (IV) victimization, including physical and sexual assault. IV is a risk factor for mental and behavioral health difficulties such as posttraumatic stress disorder (PTSD) and substance use disorder (SUD). Consistent with the self-medication hypothesis, PTSD may explain elevated SUD among IV survivors. Yet, few studies have investigated whether PTSD may have differential mediating effects for different substances, which has significant treatment implications. Methods: In 124 women (M age = 35.37, SD = 11.90) in substance use treatment, we examined PTSD symptoms as a mediator between IV and severity of different types of substance use, including alcohol, cannabis, cocaine, and opioid use. Participants completed self-report measures including the ASSIST, PCL-5, and LEC-5. Data were analyzed using path analysis in Mplus 8.3. Both dichotomous and continuous outcomes of problematic substance use outcomes were examined. Results: Most women (53.3%) reported problematic substance use with at least one substance, including opioids (39.7%), cocaine (13.0%), alcohol (9.6%), and cannabis (5.6%). Most (83.2%) of the sample reported at least one IV incident. On average, women reported clinically significant PTSD symptom severity. When problematic substance use was examined dichotomously, findings revealed significant indirect effects from IV exposure to opioid (β = 0.10, p = .010) and cocaine use (β = 0.07, p = .039) via elevated PTSD symptoms. There were no significant indirect effects for problematic alcohol (β = 0.03, p = .260) or cannabis use (β = 0.02, p = .562). When substance use was examined continuously, results revealed significant indirect effects from IV exposure to opioid (β = 0.09, p = .017), cocaine use (β = 0.09, p = .015), and alcohol use (β = 0.08, p = .020) via elevated PTSD symptoms. Indirect effects for cannabis use remained nonsignificant (β = 0.05, p = .100). Conclusions: IV survivors may be particularly at risk for opioid and cocaine misuse because of elevated PTSD symptoms. Treatments that integrate PTSD and SUD are needed to simultaneously target traumatic stress and substance use. Women with opioid and cocaine misuse may particularly benefit from trauma-focused exposure-based psychotherapy to reduce symptoms of PTSD, and thus, decrease opioid and cocaine misuse.

Childhood trauma and food addiction: The role of emotion regulation difficulties and gender differences

OBJECTIVE

Childhood trauma has been associated with substance use disorders (SUDs), but less research has investigated its association with food addiction (i.e., compulsive intake of highly processed foods containing refined carbohydrates and/or added fat). Existing research on childhood trauma and food addiction has focused primarily on women from restricted samples. Further, emotion dysregulation difficulties are implicated in both childhood trauma and food addiction, but research has not explored whether it may play a mediating role.

METHOD

Thus, the current study utilizes a sample of 310 participants recruited from Amazon Mechanical Turk (mean age = 41.3 years old, 47.4% men, 78.7% white) to investigate the mediating role of emotion dysregulation in the association between childhood trauma and food addiction. We also conducted exploratory analyses to investigate for gender differences in these associations. Gender-stratified correlational matrixes were conducted to investigate association between childhood trauma, food addiction, and emotional dysregulation. Moderated mediation models and multilevel regressions were also conducted to identify the role of gender in the association between childhood trauma, food addiction, and emotion dysregulation.

RESULTS

Emotion dysregulation was found to partially mediate the associations between food addiction and childhood trauma and gender was found to moderate associations between childhood trauma and emotion dysregulation, as well as childhood trauma and food addiction. Both moderating pathways were significantly stronger for men compared to women.

DISCUSSION

Results suggests that emotion dysregulation may be one important mediator in the association between childhood trauma and food addiction, particularly for men. The identification of other potential mechanisms contributing to the association between childhood trauma and food addiction and the use of longitudinal measurement strategies will be important in future research.

The relationship between racial discrimination and substance use: Does locus of control help explain risk?

Introduction

Exposure to racial discrimination has been consistently linked with risk for substance use. However, outside of externalizing and affect-based factors, few other mechanisms have been examined. One potential candidate is locus of control, a learning processes that involves the degree to which one attributes rewards as resulting from their own control (internal locus of control) versus outside control (external locus of control). There is evidence that exposure to stressors is associated with locus of control, with a separate body of literature linking locus of control with substance use. Thus, it is plausible that locus of control may be a mechanism underlying the relationship between racial discrimination and substance use.

Methods

The current study investigated this pathway among 503 racial/ethnic minority adults aged 18-35 who completed an online questionnaire including measures on racial discrimination related stress, locus of control, and substance use.

Results

Results indicated a significant indirect effect between racial discrimination related stress, two external domains of locus of control (i.e., powerful others and chance), and substance use. A significant indirect effect was not found for internal locus of control.

Conclusion

These findings expand our understanding on potential mechanisms that underlie the racial discrimination-substance use risk pathway among racial/ethnic minority adults, which may in turn provide important targets for substance use intervention programming.

Assault burn injuries in adolescents and adults in South Africa: risk factors and characteristics

Assault burns comprise a significant subset of burns, with a greater risk of severe injuries. This South African study used a national dataset from major hospitals to identify risks and injury characteristics of assault burns. The analysis sample comprised 2658 adolescent and adult cases and employed logistic regression with bootstrapping to examine the risk of assault compared to unintentional burns. The study indicates that 17.4% of burns were due to assault. Males were 1.5 times more likely than females to be burn assault victims. Compared to adults 55 years and older, young adults 22-39 years were at greatest risk, followed by youth 13-21 years. Assault injuries were five times more likely due to chemical attacks and three times more likely to scalds than to flame burns. The head, neck and trunk were most affected. Where alcohol was indicated, assault burns were five times more likely than unintentional burns. The findings may indicate the need for targeted prevention strategies such as conflict resolution, alcohol use management and the control of corrosive chemicals.

Indirect Associations between Middle-Childhood Externalizing Behaviors and Adolescent Substance Use through Late-Childhood Exposure to Violence

Longitudinal research to understand individual risk factors in childhood associated with exposure to violence and substance use is needed to inform prevention efforts. The present study tested indirect associations between age 8.5 externalizing behaviors and age 16 substance use through age 9.5 violence victimization and witnessing. Participants were 650 racially diverse (48.6% European American, 28.1% African American, 13.3% multiracial, and 10.0% other), predominantly socioeconomically disadvantaged youth (49% female). Externalizing behaviors were associated with higher levels of violence victimization and witnessing. The indirect path from externalizing behaviors to substance use was significant through victimization but not witnessing violence. Interventions aimed at reducing early externalizing behaviors may reduce risk for violence victimization, which may, in turn, reduce risk for adolescent substance use.

Temporal dynamics of symptom change among veterans receiving an integrated treatment for posttraumatic stress disorder and substance use disorders

The present study examined temporal patterns of symptom change during treatment for comorbid posttraumatic stress disorders (PTSD) and substance use disorders (SUDs). We hypothesized that PTSD symptom severity would predict subsequent-session substance use and that this association would be particularly strong among patients who received an integrated treatment versus SUD-only treatment. Participants were 81 United States military veterans with current PTSD and an SUD who were enrolled in a 12-week, randomized controlled trial examining the efficacy of an integrated treatment called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) compared with cognitive behavioral relapse prevention therapy (RP). Lagged multilevel models indicated that PTSD symptom improvement did not significantly predict the likelihood of next-session substance use (likelihood of use: B = 0.03, SE = 0.02, p = .141; percentage of days using B = -0.02, SE = 0.01, p = .172. Neither substance use, B = 1.53, SE = 1.79, p = .391, nor frequency of use, B = 0.26, SE = 0.50, p = .612, predicted next-session PTSD symptom severity in either treatment condition. Stronger associations between PTSD symptoms and next-session substance use were expected given the self-medication hypothesis. Additional research is needed to better understand the temporal dynamics of symptom change as well as the specific mediators and mechanisms underlying symptom change.

[Comorbidity of posttraumatic stress disorder and addiction from a biopsychosocial perspective]

Posttraumatic stress disorder and substance use disorder often co-occur within the health care system. Their comorbidity is associated with more serious acute clinical symptomatology, more frequent hospital admissions in state of emergency and significantly lower chances of improvement by psychological and pharmacological treatment. Their comorbidity contributes to dramatically unfavourable courses of illness as regards all biopsychosocial levels. The survey presented will discuss empirical findings from various perspectives: general epidemiology, substance use disorder as risk factor of trauma and PTSD, trauma and PTSD as risk factor of SUD, neurobiological effects of SUD converging towards neurobiology of PTSD, shared common factors of genetics/epigenetics, personality traits, and early developmental stress and trauma. The main focus of analysis will be put on processes that are intrinsically linked to the development and course of both disorders.

Disentangling the Symptom-Level Nuances in Comorbid Posttraumatic Stress Disorder and Problematic Alcohol Use in Northern Irish Military Veterans: A Network Analysis

Posttraumatic stress disorder (PTSD) and alcohol use are highly prevalent among military veteran populations. Several theories have been proposed to account for the comorbidity between PTSD and problematic alcohol use, but research examining the symptom-level associations between the two is limited. The current study used network analysis to examine the associations between PTSD and problematic alcohol use. Data were collected through a cross-sectional survey of veterans of the United Kingdom Armed Forces living in Northern Ireland. The sample comprised 511 (91.2% male) veterans with a history of trauma exposure and current alcohol use. A network consisting of PTSD symptoms from the PTSD Checklist for DSM-5 (PCL-5) and items from the Alcohol Use Disorders Identification Test (AUDIT) was constructed, and the bridge centrality of all items was estimated to identify items with the highest number of associations and the strongest associations between the two constructs. The PTSD symptom "reckless behavior" (2.43) had the highest bridge centrality values and thus the strongest connections and most connections to the alcohol use items. For the alcohol use items, "not being able to stop drinking" (2.31) and "number of drinks" (1.24) demonstrated the strongest bridge connections to the PTSD items. These results highlight the role of specific PTSD symptoms involved in the interaction between PTSD and problematic alcohol use.

Drugs age-of-onset as a signal of later post-traumatic stress disorder: Bayesian analysis of a census protocol

Individuals with PTSD have an increased risk of drug use disorders. Conversely, we aim to evaluate how early onset of alcohol, tobacco and psychoactive drugs use are associated with PTSD later in life. 2,193 brazilian young adults completed modularized assessments: The Trauma History Questionnaire, Post-Traumatic Stress Disorder Checklist-Civilian Version (PCL-C, transformed to PCL-5 through a crosswalk procedure), the Barratt Impulsivity Scale; and a survey on drug use with self-report questions about first use, current use, frequency, quantity, and interpersonal consequences. Bayesian inference and multivariate regression models were used to examine the effects on the risk of PTSD, considering different assumptions of information flow. Raw and unbiased (multivariate) estimates consistently revealed that earlier age of onset of alcohol and tobacco use increased risk for PTSD (Odds-ratios between 2.39 and 3.19 (Alcohol) and 1.82 to 2.05 (Tobacco). Among those who had PTSD (310), 10.3% (32) were very precocious at the onset age (12 to 18 years) of alcohol consumption (No-PTSD: 89 out 1883, 4.7%). Data supports a model in which age of onset effects are partially mediated by the number of trauma exposures. Early intoxication might suggest vulnerability for qualifying trauma events, or it may increase chances of exposure. Also, PTSD may be more likely to occur among trauma-exposed individuals with early intoxicating experiences due to alcohol or drug self-administration. The last possibility resonates with the idea that early intoxication might disrupt adolescent brain development, with a subsequent reduction in resilience when qualifying trauma events occur.

Associations between Impulsivity and Exercise Addiction, Disordered Eating, and Alcohol Use Behaviors: A Latent Profile Analysis

BackgroundDespite the known negative consequences of exercise addiction and preliminary evidence suggesting that it may co-occur with other health risk behaviors, no studies to date have examined exercise addiction among college students in conjunction with disordered eating behaviors and alcohol use. The aim of this study was to describe which college students are most at-risk for co-occurring health risk behaviors to enhance the efficiency of health risk prevention efforts. Method: Guided by multidimensional theories of impulsivity and substance use models of comorbidity, this study used latent profile analysis to examine whether separate, conceptually meaningful profiles of risk for exercise addiction, disordered eating behaviors, and alcohol use would emerge among 503 college students from a large public university. Results: The best-fitting model supported three profiles. MANOVA results revealed significant profile differences based on exercise addiction, binge eating, purging, laxative/pill/diuretic use, exercising longer than 60 minutes, negative urgency, and problematic alcohol use. Profile 3 students (n = 29), labeled the Affect Driven Health Risk-Takers, demonstrated the highest levels of impulsivity (i.e., negative urgency, lack of premeditation, lack of perseverance, and sensation seeking) and the most risk behaviors compared to the other two profiles. Profile membership was associated with distinct levels of negative urgency, exercise addiction, disordered eating behaviors, and problematic alcohol use. A small proportion of undergraduates demonstrated co-occurring exercise addiction, disordered eating behaviors, and problematic alcohol use. Profile membership also predicted the health outcomes of clinically significant exercise addiction and hazardous alcohol use. Conclusions: Findings illuminated how patterns of risk behavior engagement were associated with clinically significant exercise addiction and hazardous alcohol use and will inform prevention efforts and clinical interventions with at-risk college students.

Substance-induced psychosis as a risk factor for unipolar depression or anxiety disorders-A nationwide register-based prospective cohort study

BACKGROUND

Substance-induced psychosis has previously been linked to increased incidence of schizophrenia and bipolar disorder. We aimed to investigate if substance-induced psychosis is associated with increased risk of depression or anxiety.

METHODS

We conducted a nationwide prospective register-based cohort study from 1994 to 2017, including all individuals with substance-induced psychosis, and age-and-sex matched controls without substance-induced psychosis. We investigated time to either depression or anxiety, as well as time to depression and time to anxiety, in stratified Cox regression models.

RESULTS

We included 5,557 individuals with substance-induced psychosis and 55,562 controls. Substance-induced psychosis was associated with increased risk of either depression or anxiety (HR=7.05, 95% CI 6.71-7.41), depression (HR=5.40, 95% CI 4.77-6.11), or anxiety (HR=7.05, 95% CI 5.99-8.31). Analyses of individual types of substance-induced psychosis revealed similar hazard ratios across substances. Associations between substance-induced psychosis and depression or anxiety were stronger in people without preceding alcohol or substance use disorders. While strongest shortly after incident substance-induced psychosis, the increased incidence of depression and anxiety remained more than double over the full period of follow-up.

LIMITATIONS

Only psychiatric disorders treated either in psychiatric inpatient or outpatient units, supplemented with information on psychiatric medication, was available. Exact times of onset were similarly unknown, and only dates of first treatment were available.

CONCLUSIONS

Substance-induced psychosis is a strong predictor of later onset of depression or anxiety. Regardless of whether this association is causal, this highlights the need for increased monitoring and possibly improved treatment of patients with substance-induced psychosis.

The relationship between substance use, prior trauma history, and risk of developing post-traumatic stress disorder in the immediate aftermath of civilian trauma

Many reports have documented the relationship between post-traumatic stress disorder (PTSD) and substance use. Substance use is commonly comorbid with PTSD and is a risk factor for trauma exposure. The aim of this study was to prospectively examine how recent substance use, abuse, or dependence influenced the development of PTSD in the context of a prior trauma history, including child abuse, and the severity of initial trauma reactions. Participants (N = 81) were recruited and assessed at the emergency department of a large urban hospital in Miami and serum levels of common drugs of abuse were measured. Although substance use appeared to be a risk factor for trauma exposure, neither self-reported nor blood toxicology influenced the development of PTSD. Positive toxicology screens were more likely to be associated with a diagnosis of substance abuse or dependence, χ² (1) = 4.11, p = .04. Participants with a history of physical abuse were more likely to have a positive toxicology screen, χ² (1) = 4.03, p = .05. The majority of our trauma-exposed subjects (66%) were found to be positive for one or more illicit substances at presentation at the ED. The current findings provide support for the "high risk" hypothesis in which substance use is associated with increased trauma exposure.

The relevance of post-traumatic stress disorder as a moderator of the relationship between experience of violent or sexual assault and opioid use in adulthood

BACKGROUND

Past research has indicated that individuals suffering from post-traumatic stress disorder (PTSD) may demonstrate increased sensitivity to stress exposure following onset of the disorder. Thus, having PTSD may amplify the effects of subsequent stressors. This has been found to be relevant in some forms of substance use but relationships between PTSD, new stress and opioid use specifically has not been examined.

AIMS

To explore interactions between PTSD, new victimisation and opioid use and test the hypothesis that PTSD will moderate any victimisation-opioid use relationship.

METHODS

The pathways to desistance data were used in analyses. A series of logistic regression models were used to test both direct effects of victimisation and PTSD on opioid use and interactions between them.

RESULTS

The sample was comprised of a male majority (male N = 1,170; female N = 184). Results indicated that neither PTSD nor victimisation were significant predictors of opioid use. PTSD was found to moderate the relationship between victimisation and opioid use in the hypothesised manner.

CONCLUSIONS

There may be clinical implications of these results relating to both inpatient and outpatient treatment. Regular trauma screening, additional victims' services and trauma-informed care may help to reduce the risk of opioid use among individuals suffering from PTSD.

Disentangling the association between PTSD symptom heterogeneity and alcohol use disorder: Results from the 2019-2020 National Health and Resilience in Veterans Study

Veterans are at increased risk of comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) relative to civilians. Few studies have explored the association between distinct PTSD symptoms and AUD in veterans, and existing findings are highly discrepant. This study aimed to address this gap and equivocal association by evaluating which PTSD symptom clusters are most associated with AUD in a veteran sample using the 7-factor 'hybrid' model of PTSD. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (NHRVS), a nationally representative survey of 4069 U.S. veterans. Veterans completed self-report measures to assess current PTSD symptoms and AUD. Multivariable logistic regression and relative importance analyses were conducted to examine associations between the 7-factor model of PTSD symptoms and AUD. Adjusting for sociodemographic, military, trauma factors, and depressive symptoms, scores on the dysphoric arousal (20.7% relative variance explained [RVE]) and externalizing behaviors (19.0% RVE) symptom clusters were most strongly associated with AUD in the full sample, while externalizing behaviors (47.7% RVE), anxious arousal (23.9% RVE), and dysphoric arousal (12.4%) accounted for the majority of explained variance in veterans who screened positive for PTSD. Results of this nationally representative study of U.S. veterans highlight the importance of externalizing behaviors and arousal symptoms of PTSD as potential drivers of AUD in this population. The 7-factor hybrid model of PTSD provides a more nuanced understanding of PTSD-AUD associations, and may help inform risk assessment and more personalized treatment approaches for veterans with and at-risk for AUD.

Understanding the relations among adverse childhood experiences (ACE), substance use, and reoffending among detained youth

BACKGROUND

System-involved youth experience elevated rates of exposure to adverse childhood experiences (ACE), which is related to reentry in the criminal legal system and increased risk of using substances, but there is little research on the indirect role of substance use in the relation between adversity and offending in youth offenders. Notably, the majority of youth report exposure to multiple adverse events and these experiences vary by gender.

OBJECTIVE

The present study aimed to expand upon current literature by evaluating gender differences in the relations among cumulative ACEs, substance use severity, and reoffending in a sample of rural detained youth (N = 417).

METHODS AND RESULTS

Using Poisson (count) regression analyses, cumulative adversity significantly predicted reoffending among girls and boys. Additionally, there was a significant indirect effect of ACEs on reoffending via substance use. Girls reported higher exposure to adversity and substance use, and gender significantly interacted with ACEs to predict substance use and reoffending.

CONCLUSIONS

These findings demonstrate the importance of cumulative experiences of adversity in childhood and substance use as predictors of youth reentry into the criminal legal system. Understanding the role of substance use in the relation between ACEs and reoffending has the potential to contribute to our knowledge of detained youth's treatment needs and reoffending risk.

Mental Health Correlates of Probable Posttraumatic Stress Disorder, Probable Alcohol Use Disorder, and Their Co-Occurrence among Firefighters

Firefighters demonstrate high rates of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Research has yet to compare how these diagnoses and their co-occurrence relate to firefighter mental health. This study evaluated trauma load, PTSD, alcohol use, depression, sleep, suicide risk, anger, and occupational stress across four discrete groups of firefighters (N = 660): (1) trauma-exposed only (n = 471), (2) probable PTSD-only (n = 36), (3) probable AUD-only (n = 125), and (4) probable PTSD-AUD (n = 28). Firefighters completed an online survey. Firefighters with probable PTSD-AUD demonstrated higher scores on all criterion variables, except trauma load, compared to firefighters with probable AUD-only or trauma-only. Firefighters with probable PTSD-AUD and probable PTSD-only reported similar levels of all indices, except alcohol use severity and suicide risk, which were higher among the probable PTSD-AUD group. Results provide preliminary empirical evidence of the deleterious impact of PTSD-AUD comorbidity among firefighters.

Longitudinal assessment of PTSD and illicit drug use among male and female OEF-OIF veterans

OBJECTIVES

Posttraumatic stress disorder (PTSD) and substance use share both directional ("self-medication") and mutually-reinforcing associations over time. Research on gender differences regarding the co-occurrence of PTSD and substance use over time remains limited and largely focused on alcohol use; less is known regarding the co-occurrence of PTSD and illicit drug use, especially among veteran men vs. women. As the proportion of women in the military expands, we believe a greater focus on gender differences is warranted.

METHOD

We conducted a cross-lagged panel analysis of PTSD symptoms and drug use problems using two waves of data from a large, nationwide longitudinal registry of post-9/11 veterans. Participants included 608 men and 635 women (N = 1243; M_age = 42.3; 75.2% White) who completed self-report PTSD and drug use problem questionnaires at T1 and again at T2 15-37 months later.

RESULTS

Veteran men reported more severe drug use and related problems overall, yet the cross-sectional correlation between PTSD and drug use problems was strongest among drug using veteran women. In our cross-lagged models, we found that PTSD symptoms predicted future drug use problems among veteran men, whereas drug use problems predicted future PTSD symptom severity among women.

CONCLUSIONS

These results support the self-medication pathway among veteran men but not women, for whom drug use problems might prolong or exacerbate PTSD symptom severity over time. These results are consistent with some emerging evidence but also provide novel insight into functional associations governing the longitudinal course of PTSD and drug use problems for men vs. women.

Predicting adolescent alcohol and other drug problems using electronic health records data

IMPORTANCE

Alcohol and other drug (AOD) use problems may cause significant burden on affected adolescents and their families, yet treatment providers often do not identify these problems early enough.

OBJECTIVE

To develop, and internally and externally validate a multivariable prediction model of adolescent AOD problems using child- and maternal-level predictors before age 12, and child-level predictors between ages 12 to 18, as recorded in the electronic health records (EHR).

DESIGN

A retrospective cohort study conducted time-to-event analyses using Cox proportional hazards models.

SETTING AND PARTICIPANTS

41,172 children born between 1997 and 2000 at four health plans (Kaiser Permanente Hawaii, KPHI; Kaiser Permanente Northern California, KPNC; Geisinger Clinic, GC; and Henry Ford Health System, HFHS) who had continuous membership since birth and linkable maternal records in the health plan.

OUTCOMES

AOD use problems between ages 12 to 18, defined as either: 1) having a contact with the AOD treatment program or 2) receiving a non-tobacco AOD diagnosis in an inpatient or outpatient encounter.

EXPOSURES

Candidate predictor variables include demographics, socioeconomic status, and clinical diagnoses of the children and the mothers.

RESULTS

Overall, 1400 (3.4%) adolescents had an AOD disorder between ages 12 to 18; the median follow-up time post-age 12 was 5.3 years. The research team developed two final prediction models: a "baseline" model of 10 child-level and 7 maternal-level predictors before age 12, and a more comprehensive "time-varying" model, which incorporated child risk factors after age 12 as time-varying covariates in addition to the baseline model predictors. Model performance evaluation showed good discrimination performance of the models, with the concordance index improved for the time-varying model, especially for prediction of AOD events in late adolescence.

CONCLUSIONS AND RELEVANCE

This study identified a number of child and maternal characteristics and diagnoses routinely available in EHR data as predictive of risk for developing AOD problems in adolescence. Further, we found that risk of developing problems varies significantly by the timing and persistence of the risk factors. Findings may have potential clinical implications for prevention and identification of adolescent AOD problems, but more research is needed, especially across additional health systems.

Is Delinquency Associated With Subsequent Victimization by Community Violence in Adolescents? A Test of the Risky Behavior Model in a Primarily African American Sample

OBJECTIVE

Victimization is common in adolescence and is associated with negative outcomes, including school failure, and poor emotional, behavioral, and physical health. A deeper understanding of the risk of victimization can inform prevention and intervention efforts. This study tests the risky behavior model in adolescents, examining prospective associations between mean levels of and changes in delinquency and risk for victimization over four annual data collections.

METHOD

Low-income adolescent (53.6% female; M _age = 12.13 years, SD = 1.62 years; 91.9% African American) and maternal caregiver dyads (N = 358) residing in urban neighborhoods in the mid-Atlantic region of the United States that had moderate-to-high levels of violence and/or poverty completed separate annual home interviews for 4 years. Maternal caregivers reported on adolescents' delinquent behavior; adolescents reported on their victimization by community violence experiences.

RESULTS

Using a latent difference score model, results supported the risky behavior model for the first 2 years, but not the final data collection period. That is, levels of and changes in delinquent behavior were associated with more victimization by community violence at the subsequent time point for the first 2 study years. In contrast, there was no evidence for the opposite, specifically that victimization by community violence predicted delinquency.

CONCLUSION

Knowing that both levels of delinquency and increases in delinquency place youth at heightened risk for victimization by community violence provides impetus to intervene. Screening for increases in delinquency among youth may be one way to target youth at high risk for victimization by community violence for fast-tracked intervention.

Age of onset of adolescent binge drinking is differentially associated with cortical thickness in post-9/11 adult Veterans

BACKGROUND

Adolescence is a critical period for neural development and has been associated with high rates of alcohol abuse. This research examined potential long-term brain and behavioral effects of early versus late-onset adolescent binge drinking in an adult sample of post-9/11 Veterans.

METHODS

We compared cortical thickness measures in Veterans with a history of binge drinking that began before the age of 15 (n = 50; mean age = 32.1 years) to those with a history of binge drinking with onset after the age of 15 (n = 300; mean age = 32.1 years). Data processing was conducted with FreeSurfer. A targeted neuropsychological battery (Digit Span test, Delis-Kaplan Executive Function System Color-Word Interference Test, California Verbal Learning Test-II) was used to examine the relationships between cortical thickness and attention, memory, and inhibition. A reference group of social drinkers with no history of early binge drinking (n = 31) was used to provide normative data.

RESULTS

Early-onset adolescent binge drinkers (EBD) had greater cortical thickness in several regions than late-onset adolescent binge drinkers (LBD); both binge-drinking groups had greater cortical thickness than the reference group. There was a stronger negative association between cortical thickness and age in EBDs than LBDs in the (i) lateral orbitofrontal cortex, (ii) supramarginal gyrus, (iii) paracentral lobule, and (iv) anterior caudal cingulate. Poorer performance on the attention and inhibition tasks in the EBDs was also associated with thicker cortices.

CONCLUSIONS

This study demonstrates greater cortical thickness across frontoparietal regions in adults who began binge drinking in early versus late adolescence. A stronger negative association between cortical thickness and age in the EBDs suggests that early-onset adolescent binge drinking may be associated with accelerated cortical thinning. Thicker cortex in these regions, which are known to mediate inhibitory control, may increase impulsive behavior and contribute to the risk of alcohol addiction.

Escaping the past and living in the present: a qualitative exploration of substance use among Syrian male refugees in Germany

Background

Syrians have been the largest group of refugees in Germany since 2014. Little is known about Syrian refugees` perspectives on substance use. The aim of this study is to investigate the perspective of male refugees from Syria and to foster specific knowledge and understanding of substance use.

Methods

We applied a qualitative study design. Five semi-structured focus group discussions with a total of 19 refugees were conducted in 2019 among the difficult to reach population of Syrian refugees. Audio recordings were translated and transcribed. We used a hybrid approach by integrating inductive and deductive thematic frameworks.

Results

We identified common themes. Firstly, refugees perceived that substances are widely available and accepted in Germany. Secondly, refugees perceived that rules and norms in Germany differ from rules and norms in the home country and favor availability of substances. Thirdly, substance use is related to the intention to escape the past. Fourthly, substance use is related to living in the present through connecting with others and being part of the community. Finally, mental health professional treatment for substance use is associated with shame.

Conclusions

Findings support Syrian refugees` perspectives of substance use as a way of both escaping the past and coping with psychosocial difficulties in the present in a socio-ecological understanding. Understanding the explanatory model of Syrian refugees can inform future interventions to prevent substance abuse and design tailored interventions. Further studies with Syrian refugees in more countries are needed to better understand resettled refugees` perspectives on substance use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00352-x.

Drinking to Cope with Posttraumatic Stress: A Nationally Representative Study of Men with and without Military Combat Experience

Posttraumatic stress disorder (PTSD) and hazardous alcohol use are prevalent among trauma survivors. Despite higher rates of both PTSD and hazardous alcohol use among military combat veterans than civilians, scant research has examined whether military combat experience is associated with drinking alcohol to cope with PTSD symptoms. This study tested the hypothesis that compared to trauma-exposed men without combat experience, men with military combat experience would be more likely to endorse drinking alcohol to cope with their PTSD symptoms. Methods: Interview data from N = 11,474 men who reported at least one lifetime traumatic experience were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a face-to-face interview study that recruited a nationally representative sample of adults living in the United States between 2004 and 2005. Results: Among men endorsing lifetime trauma exposure, men with military combat experience (n = 1,386) were more likely than men without combat experience (n = 10,088) to report drinking alcohol to cope (7.22 vs. 2.61% in unweighted analyses, 6.46 vs. 2.37% in weighted analyses). Total number of lifetime trauma types, lifetime PTSD severity, and lifetime alcohol abuse/dependence were significantly associated with drinking to cope in bivariate and multivariate analyses. Military combat experience was significantly associated with drinking to cope in multivariate analyses adjusting for lifetime PTSD diagnosis. Military combat experience was not significantly associated with drinking to cope in multivariate analyses adjusting for lifetime PTSD symptom count. Conclusions: Although military combat experience was significantly associated with drinking to cope in bivariate analyses, multivariate analyses yielded mixed findings: combat experience was significantly associated with drinking to cope in models adjusting for PTSD diagnosis, but not in models adjusting for PTSD symptom count. Findings highlight the importance of assessing and targeting PTSD symptom-related alcohol use, even in the absence of alcohol abuse/dependence. Results from this preliminary study could inform future research on drinking to cope with PTSD symptoms among military combat veterans and other trauma survivors.

The role of positive emotion dysregulation in the relationship between childhood abuse and PTSD in a community sample of veterans

BACKGROUND

The co-occurrence of childhood abuse and posttraumatic stress disorder (PTSD) among United States military veterans is highly prevalent and clinically significant. Emotion dysregulation is one factor that has been found to underlie the association between childhood abuse and PTSD, yet past research has focused exclusively on dysregulation stemming from negative emotions.

OBJECTIVE

The current study extends existing research by clarifying the role of positive emotion dysregulation in the relation between childhood abuse and PTSD in a community sample of military veterans.

PARTICIPANTS AND SETTING

Participants were 465 trauma-exposed military veterans in the community (Mage = 38.00, 71.6 % women, 69.5 % White).

METHOD

Using structural equation modeling, we tested the indirect association of childhood abuse to PTSD symptom severity through positive emotion dysregulation.

RESULTS

The hypothesized model showed adequate model fit, χ2 (32, n = 465) = 176.22, p < .001, CFI = .97, RMSEA = .10, 90 % CI [.08, .11], SRMR = .04. Results showed that childhood abuse was indirectly associated with PTSD symptom severity through positive emotion dysregulation.

CONCLUSIONS

This finding highlights the potential utility of targeting positive emotion dysregulation in the detection and treatment of PTSD symptoms in veterans who experienced childhood abuse.

Predictors of substance use in a clinical sample of youth seeking treatment for Trauma-related mental health problems

Child maltreatment and traumatic events are well established risk factors for adolescent substance use problems, but little is known about the unique contributions of etiological factors on trauma-exposed youths' pre-treatment substance use in clinical settings. This study examined associations between substance use and risk and protective factors measured across multiple ecological levels among a unique sample of youth seeking treatment for trauma-related mental health problems in child advocacy centers. Participants were adolescents (N = 135; 85% female; 60% white, 31% black) aged 13-17 years (M = 15.4) with ≥ 1 experience of child maltreatment or other interpersonal violence, current substance use, and ≥5 PTSD symptoms. Youth and caregivers completed validated questionnaires and clinical interviews at a pre-treatment assessment in a randomized controlled trial of a treatment for co-occurring traumatic stress and substance use. Negative binomial regression models identified different patterns of risk and protective factors for alcohol and cannabis. Clinical implications of these results are discussed, including the potential targets for integrated psychotherapies that address co-occurring substance use and traumatic stress in youth.

Can the migration process influence the clinical expression of heroin use disorder in migrants to Italy?

BACKGROUND

For some time now, there has been a strong consensus that the migration process can influence the onset, course, development, outcome, and clinical aspects of psychiatric pathologies.

METHODS

In this study, we have analyzed the influence of the migration process on the clinical expression of heroin use disorder (HUD). In a naturalistic case-control study, we compared, both at univariate and multivariate level, 30 migrant HUD (M-HUD) patients with 30 age/gender-matched Italian HUD (IT-HUD) patients. We also analyzed demographic data, drug addiction history, psychopathological symptoms, addictive behavior, and emotional reactivity to life events.

RESULTS

Compared with IT-HUD pairs, at HUD Agonist Opioid Treatment, M-HUD patients were characterized by inadequate income and the presence of legal problems. They were more frequently at stage 3 of heroin addiction, with a concomitantly less frequent use of stimulants. Their age at the onset of heroin use was greater than that of subjects in the IT-HUD group. HUD post-traumatic stress disorder spectrum was present and was more severe in all M-HUD patients, but grief reactions and maladaptive behavior were the most discriminant traits. No differences were found in terms of addictive behaviors related to heroin craving or with respect to the severity/typology of psychopathology specific to HUD.

CONCLUSIONS

The migratory process does not seem to be correlated with addictive behaviors or with psychopathology specific to HUD. It partly affects HUD history, and specifically correlates with emotional reactivity to loss and traumatic life events, so suggesting that in M-HUD individuals, the link between the migratory syndrome and HUD is very close.

Childhood Maltreatment and Risky Substance Use Behaviors: The Mediating Roles of Posttraumatic Stress Symptoms & Callous Unemotional Traits

Background: A robust relationship has been established between childhood maltreatment and risky substance use. Posttraumatic stress symptoms and callous-unemotional (CU) traits, both of which can be consequences of childhood maltreatment, have been implicated as potential mediators of this relationship, but despite phenotypic overlap have not been examined within the same model. Objective: The current cross-sectional study examined the indirect effect of childhood maltreatment severity on risky drug and alcohol use behaviors though PTSS and CU traits. Methods: Undergraduates (n = 355, 54.4% female) with childhood maltreatment histories completed questionnaires regarding childhood maltreatment, PTSS, substance use behaviors, and CU traits. Path modeling was utilized to examine indirect effects of childhood maltreatment on risky alcohol and drug use behaviors. Results: Overall the model demonstrated good fit. PTSS and CU traits were found to fully mediate the childhood maltreatment severity to risky alcohol use behaviors, with PTSS demonstrating a trending mediational effect to risky drug usage. Results support multiple pathways to risky alcohol use for individuals with childhood maltreatment histories through PTSS and CU traits, suggesting both PTSS as well as CU traits as potential targets of intervention for alcohol misuse among individuals with childhood maltreatment experiences.