Relations Between Cognitive Functioning and Alcohol Use, Craving, and Post-Traumatic Stress: An Examination Among Trauma-Exposed Military Veterans With Alcohol Use Disorder

Concurrent impact of PTSD symptoms and alcohol use on working memory and executive functioning in a U.S. adult sample

Despite high comorbidity between posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) and well-documented independent impacts of each condition on cognitive functioning, few studies have explored the concurrent effects of PTSD and AUD on cognitive control. Recent intervention studies have explored working memory (WM) and executive functioning (EF) as potential treatment targets to improve outcomes for both PTSD and AUD, but there is a need to elucidate concurrent impacts of each condition to inform intervention development. The present study examined WM and EF performance in a sample of U.S. adults in relation to current PTSD symptom and alcohol use (AU) severity. We hypothesized that there would be main effects of both PTSD symptoms and AU severity on WM and EF outcomes, with an exploration of interaction effects. A sample of 112 participants (79% white, 61% female) recruited from a larger survey study also completed follow-up WM and EF tasks. Results did not support our hypotheses regarding main effects of PTSD and AU severity on WM and EF outcomes. Significant age effects were observed on WM measures such that higher age was associated with reduced performance. An interaction effect was detected for one EF measure (decision-making), such that decision-making performances were relatively stable at low to subthreshold PTSD symptoms regardless of AU severity but declined with increasing AU at clinically elevated PTSD symptoms. Findings reflect new information regarding the impact of concurrent PTSD and AU severity on EF, and implications for future research and intervention development are discussed.

Alcohol exacerbates post-traumatic stress psychiatric behavior and its neuropathological sequalae in experimental mice: preventive effects of morin

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are very prevalent and co-occurring. It is unclear how alcohol exacerbates PTSD predicaments owing to less characterized pathophysiological mechanisms. Also, studies on pharmacological agents that can effectively reverse PTSD-AUD comorbidity have, to date, been scarce. Hence, we designed a methodological approach to investigate the pathophysiological mechanisms and pharmacological outcomes of morin, a neuroprotective flavonoid in mice. After 7 days of PTSD following single-prolonged stress (SPS) induction in mice, the PTSD mice were exposed to intermittent binge ethanol administration using ethanol (2 g/kg, oral gavage) every other day, alongside daily morin (50 and 100 mg/kg) or fluoxetine (10 mg/kg) from days 8-21. The consequences of PTSD-AUD behavior, hypothalamic-pituitary-adrenal-axis (HPA-axis) dysfunction, neurochemistry, oxidative/nitrergic stress, and inflammation were evaluated in the prefrontal cortex (PFC), striatum, and hippocampus of mice. The exacerbated anxiety-like behavior, and spatial/non-spatial memory deficits, with general depressive phenotypes and social stress susceptibility by SPS-ethanol interaction, were alleviated by morin and fluoxetine, evidenced by reduced corticosterone release and adrenal hypertrophy. SPS-ethanol exacerbates dopamine, serotonin, and glutamic acid decarboxylase alterations, and monoamine oxidase-B and acetylcholinesterase hyperactivities in the striatum, PFC, and hippocampus, respectively, which were prevented by morin. Compared to SPS-ethanol aggravation, morin reduced TNF-α and IL-6 release, malondialdehyde and nitrite levels, with improved antioxidant (glutathione, superoxide-dismutase, catalase) levels in the hippocampus, PFC, and striatum. Overall, these findings suggest that AUD-exacerbated PTSD might be primarily connected, among other mechanisms, with aggravated HPA-axis dysfunction, upregulated neurochemical degradative enzymes, enhancement of oxidative/nitrergic stress and neuroinflammation, and stereo-selectively in the mice brains, which morin abated via the preventive mechanisms.

Psychopharmacological interaction of alcohol and posttraumatic stress disorder: Effective action of naringin

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are prevalently co-occurring, important risk factors for a broad array of neuropsychiatric diseases. To date, how these two contrastive concomitant pairs increase the risk of neuropsychiatric states, notably exacerbating PTSD-related symptoms, remains unknown. Moreover, pharmacological interventions with agents that could reverse PTSD-AUD comorbidity, however, remained limited. Hence, we investigated the neuroprotective actions of naringin in mice comorbidly exposed to PTSD followed by repeated ethanol (EtOH)-induced AUD. Following a 7-day single-prolong-stress (SPS)-induced PTSD in mice, binge/heavy drinking, notably related to AUD, was induced in the PTSD mice with every-other-day ethanol (2 g/kg, p.o.) administration, followed by daily treatments with naringin (25 and 50 mg/kg) or fluoxetine (10 mg/kg), from days 8-21. PTSD-AUD-related behavioral changes, alcohol preference, hypothalamic-pituitary-adrenal (HPA)-axis dysfunction-induced neurochemical alterations, oxidative/nitrergic stress, and inflammation were examined in the prefrontal-cortex, striatum, and hippocampus. PTSD-AUD mice showed aggravated anxiety, spatial-cognitive, social impairments and EtOH intake, which were abated by naringin, similar to fluoxetine. Our assays on the HPA-axis showed exacerbated increased corticosterone release and adrenal hypertrophy, accompanied by marked dopamine and serotonin increase, with depleted glutamic acid decarboxylase enzyme in the three brain regions, which naringin, however, reversed, respectively. PTSD-AUD mice also showed increased TNF-α, IL-6, malondialdehyde and nitrite levels, with decreased antioxidant elements in the prefrontal-cortex, striatum, and hippocampus compared to SPS-EtOH-mice, mainly exacerbating catalase and glutathione decrease in the hippocampus relative SPS-mice. These findings suggest that AUD exacerbates PTSD pathologies in different brain regions, notably comprising neurochemical dysregulations, oxidative/nitrergic and cytokine-mediated inflammation, with HPA dysfunction, which were, however, revocable by naringin.

Examining factors associated with self-reported cognitive functioning in elite military settings: considerations of combat experiences and post-traumatic stress symptomology

Exposure to traumatic events is associated with post-traumatic stress symptomology (PTSS) in a variety of populations. PTSS is also associated with self-reported everyday cognitive failures, which are acknowledged attentional lapses experienced in one's naturalistic everyday environment. While a growing literature suggests that PTSS is associated with both traumatic events and attentional functions, little is known regarding similar associations in elite military cohorts, such as Special Operations Forces (SOF) personnel. Herein, we investigate if prior combat experience is associated with everyday cognitive failures, while considering the possible mediating role of PTSS. SOF personnel (N = 119) completed self-report questionnaires assessing prior combat experience, PTSS, and everyday cognitive failures. Direct and indirect associations between these metrics were examined using structural equation modeling. Mediation analyses revealed that the correspondence between combat experiences and everyday cognitive failures is mediated by the severity of subclinical levels of PTSS. Such findings suggest that greater attention to subclinical PTSS is warranted due to its significant association with everyday cognitive failures that may contribute to deleterious mission-related failures in high-demand tactical professionals, such as SOF.

Associations between health-related behaviors and self-reported cognitive symptoms in U.S. military personnel injured on deployment

Health behaviors may be core contributors to cognition and mental health following mild traumatic brain injury (TBI). The aims of the present study examined: (1) whether health behaviors including sleep duration, alcohol use, and physical activity differed in injured military personnel with and without deployment-related mild TBI history and (2) the relative contributions of health behaviors and deployment-related mild TBI history to self-reported cognitive, posttraumatic stress disorder (PTSD), and depressive symptoms. Participants included 3076 military personnel injured on deployment participating in the Wounded Warrior Recovery Project, an ongoing web-based study. Military personnel with deployment-related mild TBI history reported similar rates of physical activity and levels of alcohol problems as those without, but were less likely to report receiving the recommended duration of sleep. When adjusting for demographic and injury variables, all three health behaviors were associated with cognitive, PTSD, and depressive symptoms. Alcohol problems demonstrated significant but small effects across all outcomes measures (ηp2=.01) whereas physical activity was associated with slightly larger effects albeit still within the small range (ηp2=.02-0.04). Duration of sleep bordered a medium effect for cognitive symptoms (ηp2=.05) and was in the medium range for PTSD and depressive symptoms (ηp2=.06). Although deployment-related mild TBI history was significant in all models, effect sizes were small (ηp2=.01). Findings from the present study provide support that health behaviors have stronger effects with regard to cognitive, PTSD, and depressive symptoms compared to deployment-related mild TBI history in military personnel and, given their modifiable nature, may represent treatment targets in this population.

Impact of Alcohol Use, Traumatic Stress, and Cigarette Smoking on Cognitive Functioning in Veterans With Co-occurring Alcohol Use Disorder and Posttraumatic Stress Disorder

INTRODUCTION

Alcohol use disorder (AUD) and PTSD have high rates of co-occurrence in U.S. Military Veterans resulting in incrementally worse functional outcomes relative to having either one of these disorders alone. Cognitive dysfunction can impede one's ability to benefit from standard behavioral AUD and PTSD treatments. Cigarette smoking is also highly prevalent among U.S. Military Veterans, and cognitive dysfunction is associated with chronic cigarette use among individuals with AUD and PTSD independently. However, much less is known about to what extent cigarette smoking further impairs cognitive functioning in individuals with both co-occurring AUD and PTSD.

MATERIALS AND METHODS

U.S. Veterans with co-occurring AUD and PTSD (n = 162) completed a comprehensive cognitive assessment covering various domains: working memory, processing speed, mental switching, cognitive inhibition, auditory-verbal learning, auditory-verbal memory, and verbal fluency. To examine the impact of alcohol use, traumatic stress, and cigarette smoking on cognitive function, we conducted a three-way interaction examining the moderated effects of smoking status on the association between alcohol use and PTSD symptoms on a composite domain of global cognition.

RESULTS

Smoking status in Veterans with co-occurring AUD and PTSD moderated the relationship between alcohol use and global cognition (P = .042), such that higher levels of alcohol use in the past week were related to worse global cognitive function among Veterans cigarette smokers (P = .015) but not among nonsmokers (P = .833). On follow-up analyses of individual cognitive domains, greater alcohol use in the past week was associated with lower cognitive inhibition in smokers but not nonsmokers, with traumatic stress symptoms moderating this effect (P = .039). Additionally, smoking status moderated the relationship between alcohol use and auditory-verbal learning, such that there was a differential relationship between alcohol use and auditory-verbal learning between smokers and nonsmokers.

CONCLUSIONS

Overall, results provide evidence for the compounding impact of alcohol use, traumatic stress, and cigarette smoking on cognitive functioning. Impaired cognitive performance on a global level as well as on individual domains of cognitive inhibition and auditory-verbal learning were evident. Cognitive dysfunction may impede a Veteran's ability to benefit from therapeutic treatment, and these cognitive domains may represent potential targets for cognitive training efforts. Further, study results support smoking cessation initiatives and smoke-free policies enacted at Veterans Affairs healthcare facilities and medical centers.

Associations between changes in somatic and psychiatric symptoms and disability alterations in recent-era U.S. veterans

Cross-sectional work suggests that deployment-related posttraumatic sequelae are associated with increased disability in U.S. veterans deployed following the September 11, 2001 (9/11), terrorist attacks. However, few studies have examined the psychiatric and somatic variables associated with changes in functional disability over time. A total of 237 post-9/11 veterans completed comprehensive assessments of psychiatric and cognitive functioning, as well as a disability questionnaire, at baseline and 2-year follow-up. At baseline, higher levels of PTSD, depressive, and pain-related symptoms were associated with baseline global functional disability, semipartial r² = .036-.044. Changes in symptoms of PTSD, depression, pain, and sleep, but not anxiety or alcohol use, were independently associated with changes in functional disability, semipartial r² = .017-.068. Baseline symptoms of these conditions were unrelated to changes in disability, and cognitive performance was unrelated to disability at any assessment point. Together, this suggests that changes in psychiatric and somatic symptoms are tightly linked with changes in functional disability and should be frequently monitored, and even subclinical symptoms may be a target of intervention.

Effects of oxytocin administration on fear-potentiated acoustic startle in co-occurring PTSD and alcohol use disorder: A randomized clinical trial

Co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and particularly associated with elevation of hyperarousal compared to PTSD alone. Treatment options are limited. Oxytocin regulates physiological stress response. Intranasal oxytocin administration has demonstrated potential in reducing symptoms of both PTSD and AUD. This study addresses a gap in the literature by investigating effects of intranasal oxytocin on startle reactivity, an important potential marker of both PTSD and AUD symptomatology. This is a randomized, double-blind, placebo-controlled, within- and between-participant, crossover, dose-ranging study examining the effects of a single administration of oxytocin 20 IU versus 40 IU versus placebo on psychophysiological responses to a common laboratory fear-potentiated acoustic startle paradigm in participants with PTSD-AUD (n = 47) and controls (n = 37) under three different levels of threat. Contrary to our hypothesis, for the PTSD-AUD group, oxytocin 20 IU had no effect on startle reactivity, while oxytocin 40 IU increased measures of startle reactivity. Additionally, for PTSD-AUD only, ambiguous versus low threat was associated with an elevated skin conductance response. For controls only, oxytocin 20 IU versus placebo was associated with reduced startle reactivity.

A Systematic Review of the Balloon Analogue Risk Task (BART) in Alcohol Research

Risk-taking propensity has been crucial to the investigation of alcohol use and consequences. One measure, the balloon analogue risk task (BART), has been used consistently over the past two decades. However, it is unclear how this measure is related to alcohol outcomes. This paper systematically reviews the literature on the BART and alcohol outcomes. First, direct associations between the BART and alcohol use are reviewed including correlations, group comparisons, the BART's prediction of alcohol outcomes and BART performance after consuming alcohol. Then, potential moderators that explain when and for whom the BART is related to alcohol outcomes are reviewed. Finally, potential mechanisms that explain how the BART and alcohol outcomes are related are reviewed. This review reveals patterns in the BART suggesting risk-taking propensity may be related to changes in alcohol use over time; however, there is little evidence to suggest BART scores increase after consuming alcohol. Yet, additional research suggests adjusted average pump scores may be too simplistic for the amount of information the BART captures and understanding individual's patterns of responses on the BART is important for investigating its relation to alcohol outcomes. Finally, this review opens up several future directions for research to understand how risk-taking propensity is related to alcohol outcomes.

The Impact of Co-occurring Post-traumatic Stress Disorder and Substance Use Disorders on Craving: A Systematic Review of the Literature

The frequent co-occurrence of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs) leads to manifestations of both conditions that are more severe and more resistance to treatment than single disorders. One hypothesis to explain this synergy is the impact of intrusive memories on craving which, in turn, increases the risk of relapse among patients with substance use disorders. The aim of this systematic review is to examine this possibility by assessing the impact of PTSD and its symptoms on craving among dual disorder patients. Using PRISMA criteria, four databases were comprehensively searched up to June, 2021, in order to identify all candidate studies based on broad key words. Resulting studies were then selected if they examined the impact of PTSD or PTSD symptoms on craving, and if they used standardized assessments of PTSD, SUD, and craving. Twenty-seven articles matched the selection criteria and were included in this review. PTSD was found to be significantly associated with increased craving levels among patients with alcohol, cannabis, cocaine, tobacco, and other substance use disorders. Exposition to traumatic cues among dual disorder patients was also shown to trigger craving, with an additive effect on craving intensity when exposure to substance-related cues occurred. In addition, certain studies observed a correlation between PTSD symptom severity and craving intensity. Concerning mechanisms underlying these associations, some findings suggest that negative emotional states or emotion dysregulation may play a role in eliciting craving after traumatic exposure. Moreover, these studies suggest that PTSD symptoms may, independently of emotions, act as powerful cues that trigger craving. These findings argue for the need of dual disorder treatment programs that integrate PTSD-focused approaches and emotion regulation strategies, in addition to more traditional interventions for craving management.

Impulsivity and Cognitive Flexibility as Neuropsychological Markers for Suicidality: A Multi-Modal Investigation Among Military Veterans with Alcohol Use Disorder and PTSD

To examine relations between self-report and behavioral measures of impulsivity and cognitive flexibility with suicidal ideation and self-harm and suicide attempt history. Methods: Eighty-seven military veterans who met DSM-5 diagnostic criteria for alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) were evaluated for current suicidal ideation and self-harm, suicide attempt history, impulsivity, and cognitive flexibility. Results: Higher levels of self-reported impulsivity were associated with greater suicidal ideation and self-harm and lower behavioral inhibition was associated with greater likelihood of endorsing a suicide attempt. Conclusion: Use of multi-modal assessment of impulsivity and cognitive flexibility may aid in suicide screening and intervention among vulnerable and high-risk populations.

Effects of Oxytocin Administration on Cue-Induced Craving in Co-occurring Alcohol Use Disorder and PTSD: A Within-Participant Randomized Clinical Trial

BACKGROUND

Individuals with alcohol use disorder (AUD) are much more likely to meet criteria for posttraumatic stress disorder (PTSD) than the general population. Compared to AUD alone, those with comorbid AUD-PTSD experience worse outcomes. Prior literature suggests that oxytocin, a hypothalamic neuropeptide, may be effective in the treatment of both AUD and PTSD when administered intranasally, although specific mechanisms remain elusive.

METHODS

Forty-seven male patients with comorbid AUD-PTSD were administered intranasal oxytocin in a randomized, double-blind, dose-ranging (20 IU, 40 IU, and matched placebo), within-participant design with study visits at least 1 week apart. A cue-induced craving paradigm was conducted using each participant's preferred alcoholic beverage versus a neutral water cue. Self-reported alcohol craving and heart rate (HR) were recorded and analyzed using linear mixed-effect models.

RESULTS

While alcohol cues significantly induced self-reported craving and increased HR compared to neutral water cues, neither dosage of oxytocin compared to placebo reduced self-reported cue-induced alcohol craving nor cue-induced changes in HR in patients with PTSD-AUD.

CONCLUSIONS

These preliminary findings suggest that oxytocin does not affect cue-induced craving. Our results contribute to an ever-growing field of research investigating the effects of intranasal oxytocin on the symptoms of substance use disorders and will help further refine methodology and streamline future inquiries in this area.

Risk-Taking Propensity, Affect, and Alcohol Craving in Adolescents' Daily Lives

Background: Alcohol craving is common among adolescents, stronger among those with more alcohol-related problems, and predicts drinking levels in their daily lives. Yet, the conditions that predict momentary changes in craving in real time among adolescents remain unclear. Objectives: This study examined the interactive effects of momentary risk-taking propensity and affect on adolescents' alcohol craving by leveraging ecological momentary assessment (EMA) methods. Methods: Participants were 29 adolescents ages 15-19 years (55% female; 69% White; 10% Black; 17% Hispanic); 45% met criteria for alcohol dependence. Following a laboratory session that captured self-report and behavioral assessments, including the well-established Balloon Analog Risk Task (BART), participants completed multiple daily assessments of alcohol craving, positive and negative affect, and risk propensity for approximately one week. Momentary risk propensity was captured in real-world settings via an EMA behavioral task ("Balloon Game"). Results: Mixed-effects models with EMA reports (Level 1) nested within participants (Level 2) revealed the majority (74%) of variability in "Balloon Game" performance was due to within-person, momentary, fluctuations. Greater momentary positive affect predicted increased alcohol craving, but only when participants exhibited heightened risk-taking propensity. Negative affect did not influence the relation between momentary risk-taking and craving. Conclusions/Importance: Momentary fluctuations in positive affect predicted acute increases in craving but only in moments when adolescents demonstrated higher levels of risk-taking propensity, as captured with an EMA-delivered behavioral task. Momentary risk-taking assessments offer new avenues to substantiate dominant theories on the driving mechanisms of craving and alcohol use among adolescents.

Predator odor stress blunts alcohol conditioned aversion

Alcohol use disorder is highly co-morbid with traumatic stress disorders in humans, and dually diagnosed individuals cite negative affective symptoms as a primary reason for drinking alcohol. Therefore, it is reasonable to hypothesize that traumatic stress history increases the rewarding properties and/or blunts the aversive properties of alcohol. We used a place conditioning procedure to test the rewarding/aversive properties of alcohol in adult male Wistar rats with or without a traumatic stress (i.e., predator odor exposure) history, and with or without an alcohol drinking history. Because extended amygdala regions have documented roles in stress, reward, and stress-induced changes in reward, we also tested the effect of acute alcohol on CREB phosphorylation (pCREB) and striatal-enriched protein tyrosine phosphatase (STEP) expression in central amygdala (CeA) and bed nucleus of stria terminalis (BNST). Our results show that a moderate alcohol dose (1.0 g/kg) produces conditioned place aversion (CPA) that is blunted by stress history but is not affected by alcohol drinking history, and this effect differed in pair-housed versus single-housed rats. Stress history reduced pCREB expression in BNST of rats with and without an alcohol drinking history. Finally, acute alcohol effects on pCREB and STEP expression in CeA were positively associated with preference for the alcohol-paired chamber. These data suggest that stress history reduces the aversive properties of moderate alcohol doses, and that alcohol aversion is associated with acute alcohol effects on pCREB and STEP expression in the extended amygdala.

Effects of experimental pain induction on alcohol urge, intention to consume alcohol, and alcohol demand

Research suggests one determinant of alcohol consumption may be physical pain, but there is no empirical evidence that pain has a causal effect on drinking. Therefore, the primary aim of this study was to test experimental pain as a determinant of several alcohol consumption proxies: self-reported urge to drink, intention to consume alcohol, and alcohol demand. This study also was designed to test negative affect as a mediator of the effects of pain on alcohol use proxies. We hypothesized that participants randomized to experimental pain induction (vs. no pain) would report greater urge, intention, and alcohol demand, and that these effects would be mediated by increased negative affect. Participants were healthy undergraduates who were moderate-heavy drinkers (N = 61). Experimental pain was induced using a novel capsaicin-heat model intended to approximate key features of clinical pain. Results indicated that participants in the pain condition subsequently endorsed greater urge and intention to drink. Furthermore, these effects were mediated by pain-induced negative affect. We observed no effect of pain on alcohol demand. This is the first study to demonstrate a causal effect of acute pain on urge and intention to drink. Given the close association between alcohol consumption, urge and intention to drink, these findings suggest that pain may influence alcohol consumption, which can have implications for individuals with co-occurring pain and alcohol use disorder (AUD). Specifically, individuals with co-occurring pain and AUD may drink to alleviate pain-related negative affect. Therefore, improving pain-coping skills may enhance pain-management abilities, subsequently reducing coping-motivated drinking. (PsycINFO Database Record