Epidemiological evidence about the relationship between ptsd and alcohol abuse: The nature of the association

doi:10.1016/S0306-4603(98)00098-7

Addictive Behaviors

Volume 23, Issue 6, November–December 1998, Pages 813-825

https://doi.org/10.1016/S0306-4603(98)00098-7 Get rights and content

Abstract

This article uses the Bradford Hill criteria for assessing causal associations to examine the nature of the relationship between PTSD and alcohol abuse. A series of studies are presented which examine this relationship. A cross-sectional study of 2,501 subjects in a community sample examined the relationship between at-risk drinking and 11 types of traumatic events. The traumatic events associated with at-risk drinking were involvement in life threatening accidents, witnessing severe injury, rape, being the victim of serious physical assault using the CIDI. In a longitudinal study of 469 firefighters exposed to a natural disaster, PTSD was associated with both an increase and decrease in alcohol consumption and PTSD rather than exposure accounted for the changes in drinking behaviour. In three other populations, psychiatric inpatients, motor accident victims and female prisoners, the association between PTSD and alcohol abuse emphasised the clinical and public health importance of this relationship. The available evidence does nevertheless support the causal nature of this relationship. Other risk factors are necessary to predict alcohol abuse following exposure to traumatic events, although exposure to traumatic events can be caused by alcohol abuse.

Section snippets

Hypothesis 1:

PTSD is a significant risk factor and causes higher rates of alcohol abuse. This arises from the notion that alcohol is a method of self-mediation (Khantzian, 1985). The evidence for this argument comes from a variety of data. Firstly there are high rates of comorbidity of these two disorders. This is particularly observed in populations which have significant levels of disability associated with their psychiatric disorder, such as psychiatric patient populations, substance abuse clinics and

Hypothesis 2:

Alcohol abuse causes an increased rate of traumatisation because of the association between alcohol use and accidents, violence and rape (Cottler, Compton, Mager, Spitznagel, & Janca, 1992). There is little doubt that there is a significant relationship between alcohol and accidents and violence. This begs the questions as to the extent that this represents secondary victimisation where there is a cycle of traumatisation. This would suggest that there are high rates of alcohol abuse amongst

Hypothesis 3:

PTSD leads to an increase or decrease in alcohol use rather than there being a simple linear relationship. This possibility emerges to explain some of the conflicting findings which provide contradictory evidence about the nature of this relationship. A corollary of this hypothesis is that traumatic life events are associated with high or low rates of alcohol use.

Hypothesis 4:

An extension of the self-medication hypothesis suggests that alcohol abuse is associated with fewer traumatic memories in the short and long term. PTSD in those with substance abuse is more likely to go into remission than those who do not use alcohol.

There is a series of articles which have extensively reviewed these and related questions Brems & Johnson 1997, Brown, Recupero, & Stout 1996, Keane et al. 1988, Kofoed et al. 1993, Stewart 1996, Zaslav 1994, Zweben, Clark, & Smith 1994. Rather

Traumatic events lead to alcohol abuse independent of PTSD

The relationship between alcohol and PTSD could be accounted for by two pathways, assuming a causal relationship. Firstly there could be a direct relationship between trauma and alcohol abuse independent of the existence of a PTSD. The reanalysis of the North Carolina data set of the Epidemiological Catchment Area (ECA) suggested that there was a significant relationship between substance abuse and traumatisation, particularly when this had occurred in adolescents (Davidson, Hughes, Blazer, &

Biological plausibility/coherence

Kosten and Krystal (1988) have proposed a cogent argument as to how alcohol could lessen the symptoms of PTSD given the neurochemical properties of alcohol and the underlying neurobiology of PTSD. Of particular relevance is the impact of alcohol on the locus coeruleus which modulates the alarm reaction Brick & Poherecky 1983, Goddard 1958, Lynch et al. 1983. Southwick et al. (1993) using yohimbine as a probe have proposed that norepinephrine dysregulation is a central feature of the disorder.

Experimental evidence

There is considerable debate about what is an acceptable animal model for PTSD. Yehuda and Antelman (1993) argued that many of the models are general models of stress rather than true models of PTSD. This means that there is a paucity of experimental research or models for examining the impact of alcohol on the symptoms of PTSD or the alcohol consumption in animals with an experimentally induced disorder. There is some evidence from inescapable electric shock models that alcohol consumption

Analogy

The central analogy to explain the association between PTSD and alcohol abuse is a model of self-medication. It is a clinical wisdom that patients with PTSD use alcohol to relieve or control the distress associated with their self-regulation problems. Khantzian (1985) has developed such a model to explain addictive behaviour where alcohol serves to treat the affect deficits, interpersonal difficulties and hyperarousal. Possibly, the creation of an alternate mental state to the hypervigilance of

Conclusion

The Bradford Hill Criteria provide a matrix which suggests that on these criteria there is an aetiological association between exposure to traumatic stress, PTSD and alcohol abuse. The evidence to examine this relationship comes from a variety of different sources and uses different perspectives in considering the question. There is not a simple relationship, as indicated in the hypotheses proposed (which are generally supported), as alcohol abuse can increase the rates of traumatisation as a

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^☆: Professor McFarlane is President-Elect of the International Society for Traumatic Stress Studies and is President of the Australian Society for Traumatic Stress Studies.

^☆☆: The Sercis data were collected by the epidemiology unit of the South Australian Health Commission. The data are used with their permission. E. Rafalowicz, P. Papay, and J. Eden assisted in the collection of the data in the firefighters study. M. Atchison collected the data in the study of 200 motor accident victims. C. Bookless assisted in the collection of the data on the 143 psychiatric inpatients. T. Air analysed the data for this article.

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Epidemiological evidence about the relationship between ptsd and alcohol abuse: The nature of the association☆,☆☆

Abstract

Section snippets

Hypothesis 1:

Hypothesis 2:

Hypothesis 3:

Hypothesis 4:

Traumatic events lead to alcohol abuse independent of PTSD

Biological plausibility/coherence

Experimental evidence

Analogy

Conclusion

Drug and Alcohol Dependence

Comprehensive Psychiatry

Journal of the American Pharmacology Association

Biological Psychiatry

Psychological distress and alcohol use among fire fighters

Scandinavian Journal of Work, Environment, and Health

Chronic PTSD in Vietnam combat veteransCourse of illness and substance abuse

American Journal of Psychiatry

Clinical implications of the co-occurrence of the substance use and other psychiatric disorders

Professional Psychology: Research and Practice

Posttraumatic stress disorder in an urban population of young adultsRisk factors for chronicity

American Journal of Psychiatry

Ethanol-stress interactionBiochemical findings

Psychopharmacology

PTSD substance abuse morbidity and treatment utilization

Addictive Behaviours

Sercismental health survey

Psychiatric morbidity following a natural disaster—An Australian bushfire

Social Psychiatry & Psychiatric Epidemiology

Post traumatic stress disorder among substance abusers from the general population

American Journal of Psychiatry

Post-traumatic stress disorder in the communityAn epidemiological study

Psychological Medicine

Combat exposure and the etiology of post discharge substance abuse problems among Vietnam veterans

Journal of Traumatic Stress

Effect of alcohol on excretion of catechol aminecs in conditions giving rise to anxiety

Journal of Applied Physiology

The detection of psychiatric illness by questionnaire

The impact of combat on later alcohol use by Vietnam veterans

Journal of Psychoactive Drugs

A short textbook of medical statistics (11th ed.)

Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls

Archives of General Psychiatry

Synoposis of psychiatry

The interrelationship of substance abuse and posttraumatic stress disorderEpidemiological and clinical considerations

Recent Developments in Alcoholism

Posttraumatic stress disorder in the National Comorbidity Survey

Archives of General Psychiatry

The self-medication hypothesis of addictive disorders

American Journal of Psychiatry