The relationship between DSM-5 PTSD symptom clusters and alcohol misuse among military veterans

The association between PTSD symptom clusters and religion/spirituality with alcohol use among first responders

Alcohol misuse and posttraumatic stress disorder (PTSD) co-occur at high rates among first responders (e.g., law enforcement, firefighters, paramedics), underscoring the need to better understand these relations to inform intervention efforts. Identifying malleable processes relevant to the association between PTSD and alcohol among first responders could inform tailored interventions. An example of such a malleable process is spirituality. As such, the current study examined the unique relationships between PTSD symptom clusters and alcohol misuse, while also accounting for the role of select demographics and religion/spirituality, in a sample of first responders. A national online sample of first responders (N = 320) completed measures of PTSD symptomology, alcohol misuse, religion/spirituality and demographics. Hierarchical linear regression analyses revealed that PTSD Intrusion (Cluster B) symptom severity was associated with greater alcohol misuse and PTSD Avoidance (Cluster C) was associated with lower alcohol misuse. Additionally, positive and negative spiritual coping were also associated with alcohol misuse. In the context of similar research among military samples, findings suggest potentially unique associations between PTSD symptom clusters and alcohol misuse among first responders. Additionally, findings highlight the potentially protective role of religion/spirituality in this population. Future research should explore nuanced relationships between PTSD symptom clusters and alcohol misuse as well as the salience of spirituality/religion in this unique population.

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.

Lifetime trauma exposure profiles and alcohol use over time among U.S. Reserve and National Guard soldiers

Although trauma exposure is a recognized risk factor for alcohol use, research on military populations has emphasized combat exposure, with minimal consideration of exposure to other potentially traumatic events (PTEs). We aimed to (a) identify, characterize, and quantify subgroups of service members based on PTE patterns; (b) examine associations between trauma exposure subgroups and alcohol use; and (c) examine these associations longitudinally. Data were drawn from Operation: SAFETY, a longitudinal study of health and well-being among U.S. Army Reserve/National Guard soldiers (N = 478). Exposure to 15 PTEs, including childhood maltreatment, noninterpersonal events (e.g., natural disasters, accidents), interpersonal trauma, and military-related exposures, was assessed at baseline. Latent profile analysis was conducted to characterize mutually exclusive trauma profiles; profile membership was used to longitudinally predict alcohol use in generalized estimating equation models. Four exposure profiles were identified: intimate partner violence (IPV)/combat trauma (8.4%, n = 40), combat trauma (24.7%, n = 118), childhood trauma (8.4%, n = 40), and low trauma (58.6%, n = 280). In adjusted models, compared to the low trauma profile, IPV/combat profile membership was longitudinally associated with alcohol problems, OR = 2.44, p =.005. Membership in other trauma profiles was not associated with alcohol use. Within the IPV/combat profile, men had a higher risk of frequent heavy drinking than women. Results suggest a need to comprehensively screen for lifetime PTE exposure, particularly IPV, in military populations. Given the high prevalence of nonmilitary PTEs, an inclusive, trauma-informed approach to health care and service provision is warranted.

Examining the associations between PTSD symptom clusters and alcohol-related problems in a sample of low-SES treatment-seeking Black/African American adults

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) often co-occur. This comorbidity negatively influences treatment outcomes, functioning, and quality of life. To better understand the relation between PTSD and AUD, research has begun to examine the influence of PTSD symptom clusters on alcohol-related problems. The current study is the first to analyze the associations between PTSD symptom clusters and alcohol consumption and AUD symptom severity in a treatment-seeking sample of Black/African American (AA) adults with co-occurring AUD and PTSD symptoms. Examination of these associations may help to facilitate greater recovery in this underserved population by identifying more precise targets for treatment. PTSD symptom clusters were identified from both the current 4-factor model identified in the DSM-5 and from a recently proposed 7-factor model. Participants were Black/AA adults (50.6% male) who endorsed trauma exposure and were seeking treatment for alcohol misuse. The majority (66%) were unemployed and almost half (45%) reported an income at or lower than $20,000. In the 4-factor model, results showed Cluster D symptoms of PTSD (i.e., negative alterations in cognitions and mood) were independently associated with alcohol consequences. Use of the 7-factor model, which divides Cluster D into symptoms of negative affect and anhedonia, further demonstrated that only anhedonic symptoms were independently associated with alcohol consequences. No symptom clusters were uniquely associated with alcohol consumption. Results suggest the absence of positive emotions, rather than the presence of negative emotions, are primarily associated with alcohol-related problems in a sample of trauma-exposed, Black/AA adults seeking treatment for alcohol misuse.

PTSD Avoidance Symptoms Associated With Alcohol Craving in Treatment-Seeking Veteran Population

Objective: Posttraumatic stress disorder (PTSD) is one of the most frequently treated behavioral health conditions within the Department of Veterans Affairs and often co-occurs with alcohol or substance use. Past research suggests that alcohol and/or substance use may be used to cope with PTSD symptoms but there are inconsistent findings in how specific PTSD symptom clusters are associated with alcohol use disorder (AUD) or substance use disorder (SUD). Evaluating the relationship between PTSD symptom clusters and craving for individual drug of dependence may help explain these ambiguous results. Methods: Veterans (N = 167) recently engaged in mental health residential treatment were recruited to participate in a semi-structured diagnostic interview (Structured Clinical Interview for the DSM-5, Research Version [SCID-5-RV]) to assess for past 12-month history of AUD/SUD. Participants also completed the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) to assess PTSD symptoms. Results: Covarying for severity of alcohol use, avoidance symptoms were significantly associated with alcohol craving for veterans with alcohol as their drug of dependence. Covarying for severity of stimulant use, no PTSD symptom clusters were associated with stimulant craving for veterans with stimulants as their drug of dependence. Conclusions: Veterans with high levels of PTSD avoidance symptoms may experience alcohol craving symptoms because they believe that alcohol use will eliminate or alleviate thoughts, feelings, or external reminders of the trauma. These results have important clinical implications in the treatment of co-occurring PTSD and AUD.

Military service branch differences in alcohol use, tobacco use, prescription drug misuse, and mental health conditions

INTRODUCTION

Rates of substance use and mental health conditions vary across military service branches, yet branches also differ notably in terms of demographics and deployment experiences. This study examines whether branch differences in substance use and mental health outcomes persist after adjustment for a comprehensive set of demographic and deployment-related factors.

METHODS

Data on 16,699 Armed Forces Active Duty service members were from the 2015 Department of Defense Health Related Behaviors Survey. Service branch-specific prevalences were estimated for self-reports of heavy episodic drinking (HED), possible alcohol use disorder (AUD), current smoking, e-cigarette use, smokeless tobacco use, prescription drug misuse, probable post-traumatic stress disorder (PTSD), probable depression, and probable anxiety. Using logistic regression, we assessed whether branch differences persisted after adjusting for an extensive array of demographic factors (among full sample) and deployment/combat factors (among ever-deployed subgroup).

RESULTS

HED, AUD, smoking, e-cigarette use, smokeless tobacco use, depression, and anxiety were highest in the Marine Corps; prescription drug misuse and PTSD were highest in the Army. HED, AUD, smoking, smokeless tobacco use, PTSD, depression, and anxiety were lowest in the Air Force; e-cigarette use and prescription drug misuse were lowest in the Coast Guard. Demographics and deployment/combat experiences differed across branches. After adjustment, service members in the Army, Marine Corps and Navy exhibited nearly 2-3 times the odds of multiple mental health conditions and substance use behaviors relative to the Air Force.

CONCLUSION

Service branch differences were not fully explained by variation in demographics and deployment/combat experiences.

[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.

Dissociative symptomatology mediates the relation between posttraumatic stress disorder severity and alcohol-related problems

Background

Up to 50% of individuals with posttraumatic stress disorder (PTSD) endorse problematic alcohol use. Typically, these individuals present with more complex and often more severe PTSD symptoms than those who do not report problematic alcohol use. Emerging literature suggests that heightened symptoms of dissociation are likewise associated with greater PTSD symptom severity. Despite this knowledge, the role of dissociation in the relation between PTSD severity and alcohol‐related problems has yet to be examined. Here, we explore the mediating role of dissociative symptomatology on the association between PTSD severity and alcohol‐related problems within a PTSD treatment‐seeking sample.

Methods

Structural equation modeling was used to test the mediating role of dissociative symptomatology between PTSD severity and alcohol‐related problems. Participants [N = 334; mean age (SD) = 44.29 (9.77), 50% female] were drawn from a clinical intake battery database for PTSD in‐patient treatment services at Homewood Health Care, Guelph, ON, Canada. A subset of battery measures assessing PTSD severity, dissociative symptomatology, and alcohol‐related problems were submitted to analysis.

Results

A significant positive association emerged between PTSD severity and alcohol‐related problems (β = 0.127, p < 0.05) in the absence of dissociative symptomatology. Critically, however, when added to this model, dissociative symptomatology (six unique facets of dissociation assessed by the Multiscale Dissociation Inventory) mediated the relation between PTSD severity and alcohol‐related problems. Specifically, greater PTSD severity was associated with greater dissociative symptomatology (β = 0.566, p < 0.0001), which was in turn associated with greater alcohol‐related problems (β = 0.184, p < 0.05).

Conclusions

These results suggest that dissociative symptomatology plays a key role in explaining the relation between PTSD severity and alcohol‐related problems. Future studies should examine the impact of targeting dissociative symptomatology specifically in treating individuals with PTSD who endorse alcohol‐related problems.

PTSD symptom heterogeneity and alcohol-related outcomes in U.S. military veterans: Indirect associations with coping strategies

INTRODUCTION

This study investigated the role of coping strategies in mediating the relationship between the 7-factor model of posttraumatic stress disorder (PTSD) symptoms and alcohol misuse in veterans.

METHODS

Data were analyzed from 615 veterans from a nationally representative study of U.S. veterans who met criteria for probable full or subthreshold PTSD. Path analyses examined the role of self-sufficient, socially-supported, and avoidant coping strategies in mediating associations between PTSD symptom clusters and alcohol use disorder (AUD), alcohol consumption, and alcohol-related consequences.

RESULTS

Negative affect PTSD symptoms were associated with AUD through increased use of avoidant coping. Additionally, dysphoric arousal PTSD symptoms were associated with AUD; avoidant coping was associated with AUD and increased alcohol consumption; self-sufficient coping was associated with reduced AUD likelihood anhedonia symptoms with decreased use of self-sufficient coping; and negative affect with decreased use of socially-supported coping and increased use of avoidant coping.

CONCLUSIONS

Results underscore the importance of avoidant coping strategies as potential mediators of the relation between PTSD symptoms and AUD. Interventions designed to mitigate engagement in avoidant coping strategies, and to bolster engagement in self-sufficient and socially-supported strategies may help reduce alcohol misuse in veterans with full or subthreshold PTSD.

Associations Between Lifetime Panic Attacks, Posttraumatic Stress Disorder, and Substance Use Disorders in a Nationally Representative Sample

Objective: Rates of lifetime substance use disorder (SUD) are high among people with lifetime posttraumatic stress disorder (PTSD). Panic attacks are also prevalent among trauma survivors and people with SUD, yet studies on PTSD/SUD have rarely examined comorbid panic. This potentially creates additional barriers to effective treatment for people with PTSD/SUD, in that panic may be under-diagnosed among people with PTSD/SUD and consequently attenuate treatment outcome. Additionally, research on PTSD/SUD often combines people with alcohol use disorder (AUD) and people with drug use disorders (DUDs) into a single group despite evidence that these two PTSD/SUD subgroups differ along important sociodemographic and clinical variables. This study tested the hypothesis that among adults with lifetime PTSD, panic attacks would be associated with greater lifetime risk for both AUD and DUD. We also explored whether panic attacks were associated with specific DUDs that frequently co-occur with PTSD (cannabis, sedatives/tranquilizers, heroin/opioids, and cocaine). Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a cross-sectional national study. Adults with lifetime PTSD (N = 2,230) were classified into one of three groups based on diagnostic interview data: adults with PTSD/AUD (i.e., met criteria for PTSD and AUD but not DUD; n = 656), adults with PTSD/DUD (i.e., met criteria for PTSD and DUD, regardless of AUD diagnostic status; n = 643), or adults with PTSD-only (i.e., met criteria for PTSD but not AUD or DUD; n = 1,031). Results: Weighted logistic regression analyses showed that lifetime risk of PTSD/AUD and PTSD/DUD, each relative to PTSD-only, was greater for adults who were younger at the time of data collection, were male, and had a history of panic attacks. Panic attacks did not predict specific DUD diagnoses comorbid with PTSD in exploratory analyses adjusting for sociodemographic and clinical covariates. Conclusions: Findings highlight the importance of assessing and targeting panic in PTSD/SUD clinics, but suggest panic may not discriminate between specific DUDs that commonly co-occur with PTSD. Study limitations and future directions are discussed.

The Effect of Cognitive-Affective Factors on PTSD and Alcohol Use Symptoms: An Investigation on Rumination, Suppression, and Reappraisal

Background: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are mental health conditions that often co-occur. The complexity of this comorbidity is well-documented, though the role of malleable cognitive-affective factors in PTSD/AUD warrants further study. Specifically, attaining a more comprehensive understanding of the role of malleable cognitive-affective factors in individuals with symptoms of PTSD/AUD may have important implications for future research, such as in treatment-seeking individuals. Extant examinations of cognitive-affective factors have demonstrated unique associations of cognitive reappraisal, expressive suppression, and rumination in PTSD symptom severity, though these effects had yet to be explored in subgroups of comorbid PTSD/AUD.Methods: In a sample of trauma-exposed individuals (n = 334) recruited to participate through an internet labor market, we first empirically examined latent subgroups of PTSD/AUD symptoms using latent profile analysis, then included expressive suppression, cognitive reappraisal, and four dimensions in the model to elucidate their role in specific profile patterns of PTSD/AUD symptom typologies.Results: Our results support a four-class model of PTSD/AUD symptoms, with unique predictive effects of expressive suppression, problem-focused thoughts, repetitive thoughts, and anticipatory thoughts on latent profile status.Conclusions: These findings may have important implications for future research focused on examining cognitive-affective patterns as they apply to intervention techniques in treatment-seeking individuals with symptoms of PTSD/AUD.

The buffering role of higher romantic relationship satisfaction on the association of hazardous drinking with PTSD and depression symptoms among female military service members/veterans

Studies show that more positive relationship satisfaction can mitigate the effects of posttraumatic stress disorder (PTSD) and depression severity on hazardous drinking in military samples. However, past studies were not circumscribed to female service members/veterans (SM/V), who represent the fastest growing demographic in the military. Moreover, studies did not examine moderators of specific symptom clusters of PTSD and depression with hazardous drinking. Indeed, recent studies have shown that the more depressive and cognitive clusters are associated with greater dysfunction. The current study extended this literature in a convenience sample of 584 female SM/V who completed self-report measures of hazardous drinking, PTSD, depression, and relationship satisfaction. PTSD or depression severity, relationship satisfaction, and their interaction, were examined as correlates of hazardous drinking after accounting for relationship, demographic, and military characteristics. For both overall PTSD and depression severity, higher relationship satisfaction weakened their association with hazardous drinking. Such results were consistent when global scores were replaced with PTSD-related negative alterations in cognitions and mood and somatic depression symptom clusters, but not for PTSD-related dysphoric arousal, anhedonia, or non-somatic depression symptom clusters. Findings suggest that to lessen the association of PTSD or depressive symptoms with problematic drinking, interventions aimed at improving relationship satisfaction may be worth considering among women in relationships. Moreover, symptom cluster analyses show that the cognitive and depressive components of PTSD, as well as the physical symptoms of depression, are most problematic, pinpointing specific areas of function on which to intervene.

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.

Posttraumatic Stress Disorder Symptomatology and Substance Use in an Outpatient Concurrent Disorders Sample

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) present a complex and often severe clinical presentation within a concurrent disorders context. The objective of this study was to examine associations between PTSD symptoms and SUD outcomes to better understand the clinical phenomenon of comorbid PTSD and SUD. Multivariate statistical methods were used to test the hypothesis that elevated PTSD symptoms, both at the level of global severity and specific PTSD symptom clusters, are associated with greater substance use and related problems.

METHODS

Data were collected from an intake assessment battery within a specialized concurrent disorders outpatient service in Hamilton, ON. The sample comprised 326 participants (mean age = 37.19, 45.4% female). Structural equation models examined associations between PTSD and alcohol, cannabis, and substance use frequency and problems, controlling for age and sex. Alcohol was ultimately dropped from the model due to non-significant bivariate associations.

RESULTS

Higher global PTSD symptomatology was significantly associated with higher cannabis and other substance use frequency and related problems. Analyses using PTSD cluster scores showed higher scores for alterations in arousal were positively associated with cannabis-related problems, drug-related problems, and cannabis and other substance use frequency. Avoidance was significantly associated with cannabis frequency and cannabis-related problems. In general, effect sizes were small in magnitude, accounting for between 9% and 25% of variance.

CONCLUSION

Significant cluster-level associations indicate the importance of specific PTSD symptoms (hyperarousal, avoidance) in relation to substance use when identifying therapeutic targets among individuals presenting with comorbid PTSD-SUD. This multivariate approach provides a higher resolution and potentially more clinically informative representation of the complex clinical presentation of PTSD and SUD in a concurrent disorder population and could guide the development of more effective treatment paths.

The Reward System and Post-Traumatic Stress Disorder: Does Trauma Affect the Way We Interact With Positive Stimuli?

Post-traumatic stress disorder (PTSD) is a highly prevalent disorder and a highly debilitating condition. Although anhedonia is an important construct of the disorder, the relationship between PTSD and reward functioning is still under-researched. To date, the majority of research on PTSD has focused on fear: fear learning, maintenance, and extinction. Here we review the relevant literature-including clinical observations, self-report data, neuroimaging research, and animal studies-in order to examine the potential effects of post-traumatic stress disorder on the reward system. Our current lack of sufficient insight into how trauma affects the reward system is one possible hindrance to clinical progress. The current review highlights the need for further investigation into the complex relationship between exposure to trauma and the reward system to further our understandings of the ethology of PTSD.

Posttraumatic Stress Disorder and Justice Involvement Among Military Veterans: A Systematic Review and Meta-Analysis

There is evidence of an association between posttraumatic stress disorder (PTSD) and criminal justice involvement among military veterans. For this study, we systematically reviewed the literature to examine the association between PTSD and criminal justice involvement among military veterans, assess the magnitude of this association, and identify strengths and limitations of the underlying evidence. Five databases were searched for a larger scoping review, and observational studies that assessed PTSD and criminal justice involvement were selected from the scoping review database (N = 191). Meta-analyses were conducted, pooling odds ratios (ORs) via restricted maximum likelihood random-effects models. The main outcomes were criminal justice involvement (i.e., documentation of arrest) and PTSD (i.e., PTSD assessment score indicating probable PTSD). Of 143 unique articles identified, 10 studies were eligible for the meta-analysis. Veterans with PTSD had higher odds of criminal justice involvement (OR = 1.61, 95% CI [1.16, 2.23], p = .002) and arrest for violent offenses (OR = 1.59, 95% CI [1.15, 2.19], p = .002) compared to veterans without PTSD. The odds ratio of criminal justice involvement among military veterans with PTSD assessed using the PTSD Checklist was 1.98, 95% CI [1.08, 3.63], p = .014. Considerable heterogeneity was identified, but no evidence of publication bias was found. Criminal justice involvement and PTSD are linked among military veterans, highlighting an important need for clinicians and healthcare systems working with this population to prioritize PTSD treatment to reduce veterans' new and recurring risk of criminal justice involvement.

Military Combat, Posttraumatic Stress Disorder, and the Course of Alcohol Use Disorders in a Cohort of Australian Vietnam War Veterans

The present study examined the course of diagnosed alcohol use disorders (AUDs) in a cohort of Australian veterans of the Vietnam War (N = 388) who were assessed 22 and 36 years after returning home. Standardized interviews provided data on AUDs, posttraumatic stress disorder (PTSD), other psychiatric diagnoses, and combat exposure. Overall, 148 veterans (38.1%) had no history of alcohol-related diagnoses, 151 veterans (38.9%) had a past AUD diagnosis that was not current at the second assessment point, and 89 veterans (22.9%) had a current AUD diagnosis at the second assessment. Less education, lower intelligence test scores, and misconduct were individual risk factors for AUDs, as were first-interview diagnoses of PTSD, antisocial personality disorder, generalized anxiety, and dysthymia, but not depression; these variables were all nonsignificant after controlling for combat exposure and PTSD. Multinomial regression was used to assess the relative contributions of combat exposure and PTSD to the course of AUDs. Combat exposure and PTSD had different patterns of association with AUDs whereby combat exposure, but not PTSD, was associated with a history of AUDs, odds ratio (OR) = 1.02, but not with current AUDs, whereas PTSD, but not combat exposure, was associated with current AUDs, OR = 3.37. Current numbing and avoidance symptoms were associated with current AUDs, OR = 4.48. The results do not support a mutual maintenance model of PTSD and AUDs but are consistent with a self-medication model, which suggests treatment for PTSD may have beneficial effects on AUDs.

Coping strategy utilization among posttraumatic stress disorder symptom severity and substance use co-occurrence typologies: A latent class analysis

OBJECTIVE

There is a lack of research on primary prevention of posttraumatic stress disorder (PTSD) symptoms and substance use among trauma-exposed populations. To guide the development of more effective prevention efforts, the current study sought to identify underlying coping mechanisms that impact PTSD-substance use co-occurrence.

METHOD

A person-centered analytic approach (latent class analysis) examined PTSD-substance use co-occurrence typologies (classes) and identified theoretically adaptive (e.g., active coping) and maladaptive (e.g., denial) coping strategies that differentiated between classes among a sample of 1,270 trauma-exposed participants (Mage = 20.71, 73.5% female, 45.7% White).

RESULTS

Latent class analysis identified five distinct typologies, reflective of extant epidemiological and etiological work. Generally, behavioral disengagement and self-blame coping increased the likelihood of being in more severe PTSD-illicit substance use (e.g., cocaine) comorbidity classes. Positive reframing and planning differentiated between low and moderate illicit substance typologies with moderate PTSD severity. Venting, acceptance, and self-distraction differentiated between asymptomatic and moderate PTSD severity typologies with low illicit substance use.

CONCLUSIONS

Findings identify general coping strategies associated with increased likelihood of being in more severe comorbidity typologies, as well as several unique coping strategies associated with risk of transitioning between low/moderate PTSD and illicit substance use classes. Relevant interventions (e.g., trauma psychoeducation, guilt-reduction therapy, psychological first aid) that may be targets for future prevention-oriented work are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Childhood Trauma Predicts Less Remission from PTSD among Patients with Co-Occurring Alcohol Use Disorder and PTSD

Post-traumatic stress disorder (PTSD) is highly prevalent among patients hospitalized for an alcohol use disorder (AUD). Hospitalization can improve PTSD and AUD outcomes in some but not all patients, but we lack data on the baseline predictors of PTSD non-remission. This study aimed to determine the baseline risk factors for non-remitted PTSD in patients hospitalized for an AUD. Of 298 AUD inpatients recruited in a rehabilitation center (Le Courbat, France), we included 91 AUD inpatients with a co-occurring PTSD and a longitudinal assessment at baseline (T1) and before discharge (T2: 8 weeks later). Patients were assessed for PTSD diagnosis/severity (PCL-5=PTSD Checklist for DSM-5), different types of trauma including childhood trauma (LEC-5=Life Events Checklist for DSM-5/CTQ-SF=Childhood Trauma Questionnaire, Short-Form), and AUD diagnosis/severity (clinical interview/AUDIT=Alcohol Use Disorders Identification Test). Rate of PTSD remission between T1 and T2 was 74.1%. Non-remitted PTSD at T2 was associated with a history of childhood trauma (physical, emotional or sexual abuse, physical negligence), but not with other types of trauma experienced, nor baseline PTSD or AUD severity. Among patients hospitalized for an AUD with co-occurring PTSD, PTSD remission was more strongly related to the existence of childhood trauma than to AUD or PTSD severity at admission. These patients should be systematically screened for childhood trauma in order to tailor evidence-based interventions.

Alcohol Use Disorder Masks the Effects of Childhood Adversity, Lifetime Trauma, and Chronic Stress on Hypothalamic-Pituitary-Adrenal Axis Reactivity

BACKGROUND

Individuals with alcohol use disorder (AUD) and those who have experienced traumas or chronic stress exhibit dysregulated hypothalamic-pituitary-adrenal (HPA) axis reactivity. Whether and how trauma and stress histories interact with AUD to affect HPA axis reactivity has not been assessed.

METHODS

In the present study, 26 healthy male controls and 70 abstinent men with AUD were administered a pharmacologic probe [ovine corticotropin-releasing hormone (oCRH)] and psychosocial stressor to assess HPA axis reactivity. Plasma adrenocorticotropin hormone (ACTH) and cortisol were assessed every 10-20 minutes. Hierarchical clustering of multiple measures of trauma and stress identified 3 distinct clusters: childhood adversity, lifetime trauma, and chronic stress. General linear model procedures were used to examine main effects of group (AUD/control) and interaction effects of the 3 clusters upon net-integrated ACTH and cortisol response.

RESULTS

We found that higher levels of childhood adversity, lifetime trauma, and chronic stress were each associated with blunted oCRH-induced ACTH reactivity in controls, but not in the AUD group. Recent chronic stress within the prior 6 months had the strongest influence upon ACTH reactivity in the control group, and lifetime trauma, the least.

CONCLUSIONS

Childhood adversity, lifetime trauma, and chronic stress likely exert persistent, measurable effects upon HPA axis functioning in healthy controls. This association appears to be masked in individuals with AUD, potentially confounding studies examining the effects of stress, adversity, and/or trauma upon the HPA axis in this population during the protracted withdrawal phase of recovery. Future work targeting stress exposure and reactivity should consider the heightened effect of previous alcohol use relative to past adversity and trauma.

The impact of trauma characteristics on post-traumatic stress disorder and substance use disorder outcomes across integrated and substance use treatments

Proponents of complex post-traumatic stress disorder (PTSD) constructs suggest that specific trauma characteristics, such as earlier age of first trauma (trauma age) and higher number of traumas (trauma count), may obstruct PTSD symptom reduction in treatment. PTSD and substance use disorders (SUD) commonly co-occur, but the impact of trauma age and count on PTSD treatment responses in a comorbid PTSD and SUD sample is unclear. Further, no studies have examined the impact of trauma characteristics on SUD treatment outcomes or whether their impact on either PTSD or SUD outcomes varies if PTSD is directly addressed. A secondary analysis of a randomized controlled trial was conducted to examine: (1) whether trauma age and count influence comorbid PTSD and SUD (PTSD+SUD) responses during and following treatment; and (2) whether these effects differed across an exposure-based, integrated PTSD+SUD treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE) and a SUD-only focused treatment (Relapse Prevention Therapy; RPT). Individuals with PTSD+SUD randomized to COPE (n = 39) or RPT (n = 43) provided weekly measurements of PTSD and SUD. Across COPE and RPT, earlier trauma age predicted reduced SUD improvement (B = -0.01, standard error = 0.00). Trauma count did not predict changes in PTSD or SUD during or following treatment. These findings suggest that excluding individuals from exposure-based, integrated treatments on the basis of trauma characteristics is not empirically supported. However, individuals with earlier trauma ages may require additional or unique clinical attention to improve their SUD outcomes.

The Role of Impulsivity in the Association Between Posttraumatic Stress Disorder Symptom Severity and Substance Use in Male Military Veterans

High rates of posttraumatic stress disorder (PTSD) and comorbid substance use disorder (SUD) are prevalent in military veterans. However, few studies have investigated impulsivity as a risk factor for engaging in substance use behavior for individuals who are experiencing PTSD symptoms. The present study evaluated impulsivity as a moderator of the association between PTSD symptoms and alcohol/drug use. Male military veterans (N = 106) completed self-report measures of alcohol use behavior, drug use behavior, and impulsivity. Participants also completed a structured diagnostic interview to assess for PTSD. The findings indicated that impulsivity moderated the relation between total PTSD symptoms and alcohol use, B = 0.01, p = .035, along with associations between alcohol use and two of the symptom clusters: PTSD reexperiencing symptoms, B = 0.01, p = .016; and PTSD avoidance/numbing symptoms, B = 0.01, p = .029. Veterans with high levels of impulsivity were at significantly higher risk of engaging in alcohol use than veterans with low-to-average levels. Impulsivity did not potentiate the relation between PTSD hyperarousal symptoms and alcohol use nor did it moderate the association between any of the PTSD variables and drug use. Impulsivity appears to serve as a significant risk factor for alcohol use, but not drug use, for male veterans experiencing PTSD symptoms. Future studies are necessary to replicate and expand upon these findings, particularly to facilitate the development of integrated evidence-based treatments that target both alcohol use and impulsivity within the context of PTSD.

Factor Structure and Measurement Invariance of the Alcohol Use Disorders Identification Test (AUDIT) in a Sample of Military Veterans with and without PTSD

Background: The Alcohol Use Disorders Identification Test (AUDIT) was developed as a screening tool for problematic alcohol use and an intervention framework to aid those who drink excessively. While the AUDIT is widely used with at-risk populations, such as military veterans, major gaps exist in the research literature regarding the construct validity of the AUDIT in military samples. Objectives: This study assessed the factor structure and measurement invariance of the AUDIT in a large sample of Canadian military veterans (N = 1669; 94.94% male). Methods: Exploratory factor analysis (EFA) was conducted using a random subsample (n = 825) to assess the underlying factor structure of the AUDIT. Confirmatory factor analysis (CFA), using the second subsample (n = 844), was used to cross-validate the factor structure revealed by EFA and compare it to other model variants. Finally, multigroup CFAs were conducted using the whole sample to further cross-validate the factor structure and examine measurement invariance in military veterans with and without clinical elevations in posttraumatic stress disorder (PTSD) symptoms. Results: Factor analyses revealed that a modified two-factor model provided a statistically better fit to the data compared to all other model variants; yet, the results did not confirm measurement invariance across military veterans with and without clinically significant symptoms of PTSD. Conclusions/Importance: The findings are in line with increasing evidence suggesting that two subscale scores should be calculated for the AUDIT. Results further suggest that care should be taken in interpreting AUDIT scores when PTSD symptoms are present for military veterans.

The Influence of Military Service Experiences on Current and Daily Drinking

Background: An extensive public health literature associates military service with increased alcohol consumption and problematic drinking. However, few well-controlled population-based studies compare alcohol use among nonveterans and veterans with diverse military service experiences, and no such study examines everyday drinking. Methods: We use population-representative data from the 2010 and 2011 Behavioral Risk Factor Surveillance System and distinguish four groups of men: nonveterans; non-combat veterans without a psychiatric disorder (PD) or traumatic brain injury (TBI); combat veterans without a PD or TBI; and veterans (non-combat and combat combined) with a PD and/or TBI. We estimate hierarchical multivariate logistic regression models of current drinking (N = 21,947) and daily drinking (among current drinkers; N = 11,491). Results from supplemental analyses are discussed. Results: Relative to nonveterans, non-combat veterans with no PD or TBI and veterans with a PD and/or TBI, respectively, but not combat veterans with no PD or TBI, are more likely to be current drinkers. Among current drinkers, non-combat and combat veterans with no PD or TBI, respectively, are less likely than nonveterans to be daily drinkers. Conversely, among current drinkers, veterans with a PD and/or TBI are more likely to be daily drinkers than nonveterans, non-combat veterans with no PD or TBI, and combat veterans with no PD or TBI. Conclusion: We document heterogeneous and countervailing influences of military service experiences on current and daily drinking. Results indicate that harmful military service experience may be associated with an increased risk of current, moderate daily drinking, which may represent a form of self-medication.

Interactive effects of PTSD and substance use on suicidal ideation and behavior in military personnel: Increased risk from marijuana use

BACKGROUND

The current study examines the unique and interactive effects of posttraumatic stress disorder (PTSD) symptoms and days using alcohol, opioids, and marijuana on PTSD symptoms, suicidal ideation, and suicidal behavior up to 1 year, later in a high-risk sample of military personnel not active in mental health treatment.

METHODS

Current and former military personnel at risk for suicide (N = 545; M age = 31.91 years, standard deviation = 7.27; 88.2% male) completed self-report measures of PTSD symptoms, past 30 days heavy alcohol use, opioid use, marijuana use, and current suicidal ideation via telephone at baseline and 1, 3, 6, and 12 months later. PTSD symptoms and the substance use variables (and relevant covariates) were entered as predictors of changes in PTSD symptoms, the likelihood of suicidal ideation, suicidal ideation severity, and the likelihood of suicidal behavior during the 11-month follow-up period.

RESULTS

PTSD symptoms predicted PTSD symptoms 1 month later. PTSD symptoms and marijuana use predicted the likelihood of suicidal ideation 1 month later and suicidal behavior during the 11-month follow-up period. The interaction between PTSD symptoms and marijuana use significantly predicted increased PTSD symptoms over time and suicidal behavior. At high, but not low levels of PTSD symptoms, more days using marijuana predicted increased PTSD symptoms over time and the likelihood of suicidal behavior.

CONCLUSIONS

Results suggest marijuana, especially for military personnel experiencing elevated PTSD symptoms may negatively impact suicidal thoughts and behavior. These results are relevant to suggestions that medical marijuana could be used in treating or augmenting treatment for PTSD.

Posttraumatic Stress Disorder Symptom Association With Subsequent Risky and Problem Drinking Initiation

OBJECTIVES

Posttraumatic stress disorder (PTSD) and unhealthy alcohol use are commonly associated conditions. It is unknown whether specific symptoms of PTSD are associated with subsequent initiation of unhealthy alcohol use.

METHODS

Data from the first 3 enrollment panels (n = 151,567) of the longitudinal Millennium Cohort Study of military personnel were analyzed (2001-2012). Complementary log-log models were fit to estimate whether specific PTSD symptoms and symptom clusters were associated with subsequent initiation of 2 domains of unhealthy alcohol use: risky and problem drinking (experience of 1 or more alcohol-related consequences). Models were adjusted for other PTSD symptoms and demographic, service, and health-related characteristics.

RESULTS

Eligible study populations included those without risky (n = 31,026) and problem drinking (n = 67,087) at baseline. In adjusted analyses, only 1 PTSD symptom-irritability/anger-was associated with subsequent increased initiation of risky drinking (relative risk [RR] 1.05, 95% confidence interval [CI] 1.00-1.09) at least 3 years later. Two symptom clusters (dysphoric arousal [RR 1.17, 95% CI 1.11-1.23] and emotional numbing [RR 1.30, 95% CI 1.22-1.40]) and 5 symptoms (restricted affect [RR 1.13, 95% CI 1.08-1.19], sense of foreshortened future [RR 1.12, 95% CI 1.06-1.18], exaggerated startle response [RR 1.07, 95% CI 1.01-1.13], sleep disturbance [RR 1.11, 95% CI 1.07-1.15], and irritability/anger [RR 1.12, 95% CI 1.07-1.17]) were associated with subsequent initiation of problem drinking.

CONCLUSIONS

Findings suggest that specific PTSD symptoms and symptom clusters are associated with subsequent initiation of unhealthy alcohol use.

PTSD symptom severity and impulsivity among firefighters: Associations with alcohol use

Firefighters represent a unique population at high risk for trauma exposure, posttraumatic stress disorder (PTSD), and alcohol use. This study explored the main and interactive effects of PTSD symptom severity and impulsivity with regard to alcohol use severity. We hypothesized that higher levels of PTSD symptom severity and impulsivity would be related to greater alcohol use severity. Covariates included trauma load, depressive symptom severity, and romantic relationship status. The sample was comprised of 654 firefighters (Mage = 38.65, SD = 8.60) who endorsed exposure to potentially traumatic events and lifetime alcohol use. Firefighters completed an online questionnaire battery. A series of hierarchical regressions was conducted. PTSD symptom severity and impulsivity were significantly, incrementally associated with alcohol use severity, and a significant interactive effect was documented; firefighters with heightened PTSD symptom severity and impulsivity had the highest levels of alcohol use severity. This line of inquiry has great potential to inform prevention and intervention efforts for this vulnerable population. Clinical and research implications are discussed.

Alcohol Use Problems, Posttraumatic Stress Disorder, and Suicide Risk Among Trauma-Exposed Firefighters

Alcohol use problems are associated with suicidal desire and may provide an avenue to suicidal ideation and behavior. However, the influence of posttraumatic stress disorder (PTSD) on the nature of the relationship between alcohol use problems and suicide risk is not well understood. In particular, the potential for PTSD to moderate the association between alcohol use problems and suicide risk remains unexplored. The present study investigated the main and interactive effects of alcohol use problems (Alcohol Use Disorders Identification Test) and PTSD symptoms (PTSD Checklist for DSM-5) on suicide risk (Suicide Behaviors Questionnaire-Revised) in a sample of 632 trauma-exposed firefighters (93.5% men; Mage = 38.44 years, SD = 8.59). Hierarchical logistic regression analyses evaluated whether the main and interactive effects of PTSD symptom severity and alcohol use disorders were significantly related to suicide risk, above and beyond age and cumulative trauma. The main effects of PTSD symptom severity (odds ratio, 1.76; p < 0.001) and alcohol use problems (odds ratio, 1.37; p = 0.391) significantly positively predicted suicide risk; however, PTSD symptoms did not moderate an association between alcohol use problems and suicide risk after accounting for these main effects (p > 0.05). A secondary, exploratory aim demonstrated that all PTSD symptom clusters significantly positively predicted suicide risk (p's < 0.001), although none of these clusters interacted with alcohol use problems to predict suicide risk (p's > 0.05). Theoretical and clinical implications are discussed as they relate to the importance of screening for PTSD and alcohol use disorder among firefighter populations.

Alcohol and Marijuana Polysubstance Use: Comparison of PTSD Symptom Endorsement and Severity Patterns

A growing body of work links posttraumatic stress disorder (PTSD) symptoms and substance use. Unfortunately, much of the literature has examined associations in isolation (e.g., alcohol only). Failure to account for simultaneous or concurrent substance use may limit conclusions that can be drawn from existing research, including the extent to which specific substances contribute differentially to PTSD symptom patterns. The current study examined differences in PTSD symptom profiles between individuals using one or both of the most commonly co-administered psychoactive substances – alcohol and marijuana. Trauma-exposed participants (N = 533; M_age = 21.15) comprised two mutually-exclusive groups: past-month alcohol-only use (n = 334) or past-month alcohol and marijuana use (n = 199). Cluster-level and symptom-level profile analyses evaluated mean differences and shape (parallelism) of PTSD symptom severity profiles between the groups. Follow-up analyses examined symptom-specific difference in PTSD symptom endorsement and severity. Overall, individuals using marijuana and alcohol evidenced greater PTSD negative cognition (30.8% greater) and hyperarousal (26.4% greater) symptom severity. Alcohol and marijuana users were more likely to endorse, and report greater severity of, mood-related PTSD negative cognition symptoms (e.g., anhedonia, negative affect) and externalizing hyperarousal symptom (e.g., irritability/aggression, risky behaviors) than alcohol-only users. Findings highlight important PTSD differences between individuals that are often lumped into homogenous categories of isolated substance users. Findings provide preliminary support for an ‘additive’ self-medication model between PTSD and polysubstance use. Lastly, findings indicate that mood-related negative cognition symptoms and externalizing hyperarousal symptoms may be important targets for PTSD-polysubstance use intervention.

Diminished positive affect and traumatic stress: A biobehavioral review and commentary on trauma affective neuroscience

Post-traumatic stress manifests in disturbed affect and emotion, including exaggerated severity and frequency of negative valence emotions, e.g., fear, anxiety, anger, shame, and guilt. However, another core feature of common post-trauma psychopathologies, i.e. post-traumatic stress disorder (PTSD) and major depression, is diminished positive affect, or reduced frequency and intensity of positive emotions and affective states such as happiness, joy, love, interest, and desire/capacity for interpersonal affiliation. There remains a stark imbalance in the degree to which the neuroscience of each affective domain has been probed and characterized in PTSD, with our knowledge of post-trauma diminished positive affect remaining comparatively underdeveloped. This remains a prominent barrier to realizing the clinical breakthroughs likely to be afforded by the increasing availability of neuroscience assessment and intervention tools. In this review and commentary, the author summarizes the modest extant neuroimaging literature that has probed diminished positive affect in PTSD using reward processing behavioral paradigms, first briefly reviewing and outlining the neurocircuitry implicated in reward and positive emotion and its interrelationship with negative emotion and negative valence circuitry. Specific research guidelines are then offered to best and most efficiently develop the knowledge base in this area in a way that is clinically translatable and will exert a positive impact on routine clinical care. The author concludes with the prediction that the development of an integrated, bivalent theoretical and predictive model of how trauma impacts affective neurocircuitry to promote post-trauma psychopathology will ultimately lead to breakthroughs in how trauma treatments are conceptualized mechanistically and developed pragmatically.