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Alcohol Abuse in Individuals Exposed to Trauma: A Critical Review

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In this article, the author critically reviews studies on the relationship between exposure to trauma, posttraumatic stress disorder (PTSD), and alcohol abuse. After establishing that strong relationships exist between exposure to traumatic events and alcohol problems, and particularly between the diagnoses of PTSD and alcoholism, the author discusses various factors, theories, and possible mechanisms to account for these associations. Moreover, she discusses applications of these findings to the assessment and treatment of people exposed to trauma who abuse alcohol. Finally, the author outlines novel methods for testing theoretical hypotheses and makes suggestions for methodological improvements in future research.
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... For example, drinkers may perceive alcohol as able to eliminate intrusive memories of trauma, decrease traumatic psychological distress, or reduce additional undesired symptoms. Such reasons for drinking are consistent with negative reinforcement processes long theorized to underlie stress-and trauma-related drinking as articulated in self-medication, tension reduction, and distress coping models (Chilcoat & Menard, 2003;Grayson & Nolen-Hoeksema, 2005;Hawn et al., 2020;Khantzian, 1997;Stewart, 1996). Research, albeit limited, suggests that greater expectations about alcohol's ability to reduce PTSD symptoms might underlie or augment some posttraumatic drinking outcomes (Himmerich & Orcutt, 2019;McDevitt-Murphy et al., 2017), though research is mixed (Vik et al., 2008). ...
... Focus groups began with a discussion on broad reasons for drinking, with prompts informed by theoretical and empirical literature on general drinking motives/expectancies (e.g., Cooper, 1994;Cooper et al., 1995;Fromme et al., 1993). Subsequent prompts then focused on reasons for drinking in response to posttraumatic symptoms specifically, as informed by literature on PTSD-alcohol expectancies (Norman et al., 2008) and negative reinforcement or emotion regulation models of PTSD-related drinking (Chilcoat & Menard, 2003;Grayson & Nolen-Hoeksema, 2005;Hawn et al., 2020;Khantzian, 1997;Stewart, 1996). Prompts queried recent stress-/trauma-related drinking events explicitly as well as nonhabitual drinking events more broadly, with the latter anticipated to capture drinking in response to varying PTSD symptoms rather than routinized drinking because of withdrawal symptoms or typical drinking patterns. ...
... Directed content analysis (Hsieh & Shannon, 2005) was used to identify both anticipated themes as derived from theoretical/empirical literature on alcohol cognitions or PTSD-related drinking (i.e., deductive theme generation; Chilcoat & Menard, 2003;Cooper, 1994;Cooper et al., 1995Cooper et al., , 2016Fromme et al., 1993;Grayson & Nolen-Hoeksema, 2005;Hawn et al., 2020;Khantzian, 1997;Norman et al., 2008;Stewart, 1996) as well as unanticipated themes generated from focus group content (i.e., inductive theme generation). Data analyses involved three phases comprising (a) preparation, (b) organizing, and (c) reporting (Elo & Kyngäs, 2008). ...
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Posttraumatic stress disorder (PTSD) confers considerable risk for alcohol-related harms. Trauma-exposed individuals may turn to alcohol in response to intrusive trauma-related symptoms (e.g., memories, flashbacks, and nightmares) or distressing trauma-related emotions, with such desires to drink shifting dynamically in the moment in response to PTSD symptoms. However, the in-the-moment reasons for drinking that may underlie these dynamic processes remain largely unknown. The present qualitative study aimed to identify key in-the-moment PTSD-related reasons for drinking. Focus groups of frequent drinkers with a provisional diagnosis of past-month PTSD recruited from the community (n = 39; 44% female adults) provided in-depth information on their reasons for drinking during several recent drinking episodes. Focus group data were subjected to directed content analysis. The findings revealed several novel insights regarding in-the-moment reasons for PTSD-related drinking. Participants endorsed perceptions that alcohol could numb trauma-related thoughts and emotions or distract from intrusive symptoms (i.e., negative reinforcement). Participants also described perceptions that alcohol could enhance positive emotions amid persistent negative mood and help process complex trauma-related memories as well as facilitate interpersonal connection. The results identify specific, in-the-moment reasons for drinking in response to emergent PTSD symptoms, which appear at times unique from more general drinking motivations. The findings shed light on potential risk pathways for problem drinking in response to PTSD symptoms as they occur across daily life. These specific in-the-moment reasons for drinking could represent important clinical targets for real-time, adaptive interventions for comorbid PTSD and problem alcohol use.
... experiences and/or PTSD symptoms. Affectivereinforcement theories suggest that individuals drink either to ameliorate trauma-related negative affect and/ or to enhance low levels of positive affect in the aftermath of trauma (Grayson & Nolen-Hoeksema, 2005;Stewart, 1996). Affective cognitions pertaining to alcohol's ability to buffer, alter, or ameliorate affect may be crucial to posttraumatic-drinking outcomes. ...
... Alcohol cognitions related to negative reinforcement. Predominant theoretical models of posttraumatic drinking assert that alcohol use results from efforts to cope with (or medicate) distressing trauma-associated affect (e.g., tension reduction, self-medication, distress coping; Chilcoat & Menard, 2003;Grayson & Nolen-Hoeksema, 2005;Khantzian, 2003;Polusny & Follette, 1995;Stewart, 1996). These models have received the most empirical attention in posttraumatic drinking to date (see Hawn, Cusack, & Amstadter, 2020). ...
Article
Trauma and posttraumatic stress disorder (TR/PTSD) are implicated in deleterious alcohol outcomes, yet the processes that undergird these associations remain elusive. Affective (i.e., emotionally laden) cognitions may play key roles in TR/PTSD-related drinking that could inform prevention and intervention. In the present review, we synthesized extant literature ( k = 58) on affective cognitions and their role in negative- and positive-reinforcement TR/PTSD-related drinking, including alcohol-specific (e.g., drinking motives, alcohol expectancies) and non-alcohol-specific (e.g., emotion-regulation cognitions, perception and attentional biases) cognitions. Findings generally supported the importance of alcohol-specific cognitions in negative-reinforcement drinking more so than positive-reinforcement drinking. Non-alcohol-specific affective cognitions were considerably less researched. Several gaps in the knowledge base emerged; studies were overwhelmingly cross-sectional, conducted mainly within homogeneous college samples, and often did not disaggregate effects of trauma exposure from those of PTSD. Future research is needed to address these gaps to optimally inform clinical efforts to reduce TR/PTSD-related drinking risk.
... Second, an ideal victim has to be vulnerable and blameless, simultaneously, and the ideal offender should be bad or deviant. In addition, the ideal victim stereotype is influenced by individual victim-related aspects, the victim-offender relationship, the level of physical violence, induced injuries, and the victim's lifestyle (Stewart et al. 1996). In addition, Kramer (2015) in her psychological research on surfacing of the (im)possible victim and the role of gender argues that in the case of female-perpetrated sexual violence, social constructions of the victim or the perpetrator are becoming discursively problematic because these constructions imply the unlikelihood of female sexual transgression. ...
Article
In this article, we interrogate the role of affective economies in the surfacing of male victimhood in the context of sexual violence. The victim-worthiness concept speaks directly to the notions of the qualifications and characteristics of victimhood, especially in the context of gender- and sexual-based violence. The post-apartheid South African context on violence has largely been dominated by a public narrative that clearly demarcates victims and perpetrators of gender and sexual violence. In this article, we examine some ways in which male victim-survivors of sexual violence negotiate victim-worthiness in a public forum. We employ a discourse analytical approach and affect theoretical lenses to explore this negotiation and some of the tensions that it surfaces. We show how male victim-survivors of sexual violence take up different discursive positionalities to not only negotiate their victim status but also to legitimate and recognise male sexual victimhood. These discursive strategies further work in tandem with affective surfacing processes that produce a subject worthy of empathy.
... According to the self-medication model, individuals with PTSD symptoms are more likely to drink alcohol to manage these symptoms, as alcohol can temporarily stifle stress responses and reduce negative affect (Lane et al., 2019;Petrakis & Simpson, 2017). Alcohol use for self-medication of PTSD symptoms may be negatively reinforcing, which can lead to increased use and associated problems over time (Stewart, 1996). ...
... Another commonly cited RF is trauma (pre-or post-displacement), especially in the context of forced displacement because of armed conflict, the loss of associated property, social relationships, livelihoods, and identity [46,[65][66][67]. It has been suggested that harmful substance use may act as a coping strategy in response to these stressors and that alcohol consumption may constitute an attempt at behavioral self-medication [67][68][69][70][71][72]. ...
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Non-communicable diseases, previously thought of as a problem of high-income countries, now coexist in low- and middle-income countries, including the countries of origin for many refugees traveling to Europe. We aimed to describe the prevalence of risk factors for non-communicable diseases among refugees, asylum seekers, and subsidiary protection beneficiaries resettled or relocated in Portugal between 2015 and 2020 and compare these to the prevalence of risk factors in the 12 months before they left their country of origin. A cross-sectional study was conducted between 2019 and 2020 of all refugees, asylum seekers, and subsidiary protection beneficiaries attending a Lisbon, Portugal refugee center. Behavioral and biological risk factors were assessed using the WHO STEPwise modified questionnaire. A descriptive statistical analysis was conducted, which included 80 respondents, mainly men, with an average age of of 30.3 ± 9.8 years. The prevalence of several behavioral risk factors for non-communicable diseases among refugees, asylum seekers, and subsidiary protection beneficiaries was higher at the time of the study than in the 12 months before leaving the country of origin. Differences between men and women were noted in tobacco (49.1% vs. 25.9%) and alcohol use (43.4% vs. 18.5%) in the receiving country. Overweight and obesity also showed differences by gender (7.5% vs. 11.1% and 39.6% vs. 48.1%). The prevalence of suicidal ideation and suicidalplanning was high, and varied from 6.3% and 20% in the country of origin to 16.3% and 38.5% respectively in the receiving country, however the prevalence of suicide attempts was lower in the receiving country (66.7%) compared to the country of origin (100.0%). Information on health and social determinants is critical to identify priorities and increase access to access to gender-specific health and community level interventions, including mental health, to reduce risk factors associated with refugee relocation and resettlement.
... Extensive research has found that exposure to traumas causes various fatal stress-inducing psychological illnesses and behavioral problems, including suicide attempts, psychosis, alcohol use disorder, and depressive symptoms [15,21,23,24,27,29,38,39]. Depression is thoroughly intertwined with post-traumatic stress disorder (PTSD) (Elhai et al., [12]) and is a common symptom relating to these disorders and behavioral problems, especially PTSD [8]. ...
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Extensive research has established that interpersonal trauma is related to depression and dissociation severity. Extending prior research, this study found that childhood and adulthood interpersonal traumas are related to depressive symptoms and examined the role of dissociative process as a mediator. Two hundred eighty-nine adult participants retrospectively reported on traumatic experiences and current symptoms of dissociation and depression, indicating that both childhood and adulthood interpersonal traumas are related to the severity of depression. However, childhood interpersonal trauma was associated with a higher level of dissociative symptoms. Moreover, it was suggested that dissociation serves as a pathway through which childhood interpersonal trauma influences depression, although this relationship was not observed for adulthood interpersonal trauma. In conclusion, this study highlights the potential role of dissociation in the development and maintenance of depression, particularly among individuals who have experienced childhood interpersonal trauma. These findings suggest that interventions targeting dissociation show potential for mitigating retrospective depression, especially for survivors of childhood interpersonal trauma.
... More recently, Ceelen et al., (2019) also have found that reporting was significantly less likely when the rape happened in theirs or the perpetrator's home, where there was an existing relationship with the perpetrator, the age difference between themselves and the perpetrator was small, and victims voluntarily used alcohol or drugs. Engaging in 'high risk behaviours' such as drinking or using drugs is not considered 'acceptable' behaviour and is still used to blame many victim/survivors for the violence they experience (Stewart et al., 1996;Norris et al., 1992). Victims who have been drinking at the time of their attacks are more likely to question their recollection of events or worry that their drunkenness contributed to their sexual victimisation (Weiss, 2010). ...
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Following the controversy surrounding the 2018 appointment of Brett Kavanaugh to the United States Supreme Court, hundreds of thousands of victim/survivors of sexual violence took to social media to share their reasons for not reporting their experiences to the police. A sample of these tweets was collected and thematically analysed to identify the main reasons cited for the decision to not report. Results suggest that the decision to report is complex and influenced by multiple factors both within and beyond the criminal justice system including a vulnerable victim, varied types of fear, shame and blame. These findings are discussed in light of the existing literature on rape myths and the ideal victim.
... However, alcohol problems are often comorbid with symptoms of posttraumatic stress disorder (PTSD; Debell et al., 2014). Such comorbidity presents unique challenges for treatment, as individuals with these co-occurring mental health conditions show greater symptom severity, poorer social functioning, more functional health problems, less improvement over the course of treatment, earlier treatment dropout, and greater relapse relative to either condition alone (Bailey & Stewart, 2013;McCarthy & Petrakis, 2010;McCauley et al., 2012;Read et al., 2014;Stewart, 1996). Research dedicated to understanding the nature of comorbid PTSD-alcohol problems remains an important priority, with potential implications for the development and tailoring of effective interventions. ...
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A behavioral economic reinforcer pathology model theorizes that alcohol problems are influenced by steep delay discounting, overvaluation of alcohol reinforcement, and low reinforcement from alcohol-free activities. Extending this account to the comorbidity of alcohol problems and posttraumatic stress disorder (PTSD), the present study tested the hypothesis that alcohol problems and PTSD symptom severity would interact and be positively associated with indicators from these three domains. High-risk emerging adults from North America (Study 1, n = 1,311, Mage = 22.13) and general community adults from Canada (Study 2, n = 1,506, Mage = 36.80) completed measures of alcohol problems, PTSD symptoms, delay discounting, alcohol demand, and proportionate alcohol-related reinforcement. Across studies, regression analyses revealed significant main effects of alcohol problems and PTSD symptoms in relation to selected reinforcer pathology indicators, but no significant interactions were present for delay discounting or proportionate alcohol-related reinforcement. Interactions were observed for alcohol consumption at $0 (intensity) and the rate of change in consumption across the demand curve (elasticity; Study 1) and for elasticity and maximum alcohol expenditure (Omax; Study 2), but not in the predicted directions. Higher synergistic severity was associated with lower alcohol reinforcing value in each case. These findings reveal expected relations between reinforcer pathology indicators and both alcohol problems and PTSD symptomatology in general but did not support the hypothesized synergistic relationship. The relation between alcohol problems and PTSD is more complex than predicted by existing extensions of the reinforcer pathology model, warranting further investigation.
Article
Objective Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co-occur. Momentary alcohol cognitions may represent in-the-moment, modifiable risk factors to target in interventions for comorbid PTSD and AUD. However, the role of such cognitions in risk for problematic drinking as it emerges in response to individuals’ fluctuating PTSD symptoms across their daily lives remains unknown. The present study aimed to test whether state-level PTSD-alcohol expectancies and/or drinking motives modulate in-the-moment associations between PTSD symptoms and alcohol outcomes. Method Frequent drinking adults with current PTSD ( n = 54) reported on their posttraumatic symptoms and alcohol cognitions, craving, and consumption during four momentary surveys each day for 14 days (3,024 observations) in an ecological momentary assessment design. Multilevel moderation analyses tested whether in-the-moment PTSD-alcohol expectancies and/or drinking motives moderated relations of PTSD symptoms with alcohol craving and consumption. Results Findings demonstrated a significant interaction between PTSD symptoms and coping drinking motives on in-the-moment alcohol craving. Specifically, greater experience of PTSD symptoms related more strongly to craving for alcohol during events in which drinkers endorsed higher levels of coping drinking motives. There were no additional interaction effects for drinking motives or PTSD-alcohol expectancies on either alcohol craving or consumption. Conclusions Coping drinking motives appear to convey strong in-the-moment risk for PTSD-related alcohol craving yet not subsequent alcohol consumption. Future research should delineate concurrent alcohol risk and possible protective processes active in the presence of PTSD symptoms to help identify targets for interventions tailored to the unique risk processes maintaining comorbid PTSD and AUD.
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The authors used a modified Stroop task to study how people with posttraumatic stress disorder (PTSD) process threatening information. Participants were motor vehicle accident (MVA) survivors with either PTSD (n = 15), simple phobia of driving (n = 15), or low anxiety (n = 15). Participants named colors of 4 types of words: strong threat words (MVA related), mild threat words (MVA related), positive words, and neutral words. Participants with PTSD demonstrated greater interference on strong threat words than those with simple phobia or low anxiety. Contrary to expectation, participants with simple phobia did not display an interference effect. Findings suggest that individuals with PTSD and simple phobia may process threatening information differently. The nature of attentional bias in different anxiety conditions following trauma is discussed.
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Despite its relative infancy, child abuse research has provided a substantial literature on the psychological sequelae of sexual molestation. These findings have been helpful in informing social policy and guiding mental health practice. Because of the recency of interest in this area, however, as well as the costs and time investment associated with more rigorous longitudinal research, many of these studies have used correlational designs and retrospective reports of abuse. The implications of this methodology are outlined, and remedies are suggested where possible.
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Three groups of 12 nonalcoholic men at differing degrees of genetic risk for alcoholism were tested with and without alcohol for their cardiovascular response to an aversive stimulus. A high-risk group consisted of sons of alcoholic fathers with extensive transgenerational family histories of alcoholism. A moderate-risk group included sons of alcoholic fathers whose previous generation was essentially negative for other alcoholic diagnoses. The low-risk group consisted of men with negative family histories for the disorder. Heart rate and digital blood volume amplitude were measured in each subject while resting and during a signaled shock procedure. Results show that the high-risk group was more cardiovascularly reactive to the stressor than the moderate-risk group when sober. Alcohol consumption led to a dramatic reduction in the degree of reactivity in the high-risk group, and it led to increased reactivity in the moderate-risk group. The trend for the low-risk group was similar to the moderate-risk group with no significant differences between the two. The methodology and results are discussed in terms of their relevance in the etiology of alcoholism in high-risk men and in terms of the need for generational controls in studying sons of alcoholics.
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In Exp I, male nonalcoholics (aged 21–30 yrs), considered to be at heightened risk for alcoholism on the basis of high scores on the MacAndrew Alcoholism Scale (MAC), were found to show much more pronounced reduction of their cardiovascular and affective responses (as measured by the Mood Adjective Check List) to stress when they consumed alcohol (1 g/kg) than did their low-risk controls. In Exp II, with 82 Ss, a similar finding for cardiovascular responses to stress was observed when risk was predicated on the basis of low scores on the Socialization (S) scale of the California Psychological Inventory (or on the basis of combined risk on both the MAC and S scale). Results indicate that outgoing, aggressive, impulsive, and antisocial individuals who are identified by these measures may find alchohol consumption particularly reinforcing by virtue of their obtaining a greater amount of alcohol's stress-response-dampening (SRD) effect when they drink. An etiological model of alcoholism that incorporates individual differences in the SRD effects is proposed. (58 ref)