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