Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, African-American men and women☆
Introduction
Alcohol and substance use disorders confer significant burden to individuals, families, and broader social communities. At least 85,000 deaths in the United States in 2000 can be attributed to alcohol and another 17,000 to illicit substances (Mokdad, Marks, Stroup, & Gerberding, 2004), and alcohol alone accounts for 3.8% of global deaths and 4.6% of the global burden of disease and injury (Rehm et al., 2009). Alcohol and substance use disorders are associated with increased risk for a range of negative outcomes, including divorce, homelessness, partner and child abuse perpetration, psychiatric hospitalization, incarceration, and death by homicide and suicide (Collins et al., 2007, Darke et al., 2009, Grinman et al., 2010, Klostermann and Fals-Stewart, 2006, Opsal et al., 2013, Rehm et al., 2007, Slade et al., 2008, Wells, 2009). Posttraumatic stress disorder (PTSD) is commonly comorbid with alcohol and substance use disorders (Swendsen et al., 2010) and is also associated with serious social, emotional, and physical dysfunction (Boarts et al., 2006, Drescher et al., 2003, North and Smith, 1992, Taft et al., 2005). Furthermore, comorbidity of PTSD with alcohol and substance use disorders is associated with greater negative psychosocial consequences relative to either alone (Dutton et al., 2014, Mericle et al., 2012)
The reasons for the observed comorbidity of PTSD with alcohol and substance use disorders are anything but certain, and the temporal relationship between the two remains murky, given that presentations may be similar and onsets difficult to separate. Nevertheless, a robust literature suggests that trauma (particularly early developmental trauma) and PTSD often precede the development of alcohol and substance abuse (Anda et al., 2006, Kilpatrick et al., 2000, Molnar et al., 2001).
Early trauma may result in dysregulation of the stress response systems in a way that enhances vulnerability both to PTSD and to alcohol and substance use disorders (De Bellis, 2002). In a retrospective study of African-American women with current or recent cocaine abuse, the average age of first sexual assault was nine years old—at least eight years prior to average onset of alcohol or substance use and depression (Boyd, 1993). In a sample of African-American men with and without substance dependence, dependence was predicted by the interaction of child abuse with a particular polymorphism within GABRA2, a gene implicated in the development of alcohol and substance dependence, as well as PTSD, and whose expression is impacted by early life stress (Enoch et al., 2010, Nelson et al., 2009). Furthermore, the potential impact of stress on substance use has been observed in translational studies, including those demonstrating that early stress (e.g., maternal separation, prolonged isolation) results in increased cocaine self-administration in rats (Kosten et al., 2000, Meaney et al., 2002).
Moreover, the impact of early trauma on risk for developing alcohol and substance use problems is likely mediated by PTSD. In a retrospective study using path analysis, childhood rape was associated with PTSD and PTSD with alcohol use, but the direct path from childhood rape to alcohol use was not significant (Epstein, Saunders, Kilpatrick, & Resick, 1998). Moreover, in a longitudinal study, individuals with a history of exposure to trauma and a diagnosis of PTSD were at an increased risk for substance use disorder, but trauma alone did not increase risk (Chilcoat & Breslau, 1998). The authors proposed that the pattern of findings from this longitudinal study support the ‘self-medication’ hypothesis, whereby an individual is exposed to trauma, develops symptoms of PTSD, and uses substances as a means of reducing or dampening those symptoms.
Whether childhood trauma—through PTSD—is associated with risk for alcohol and substance use disorders in men and women differently remains unclear. Women are at greater risk of developing PTSD following traumatic exposure (Breslau, 2002, Kessler et al., 1995) and are more likely to develop PTSD prior to the onset of substance abuse (Sonne, Back, Zuniga, Randall, & Brady, 2003), which could suggest a greater impact of PTSD on the risk for alcohol and/or substance abuse in women. On the other hand, other studies show that men with PTSD may be more likely than women with PTSD to use alcohol, in particular, to manage negative affect and negative cognitions (Chaplin et al., 2008, Jayawickreme et al., 2012).
Incidence of comorbidity of PTSD and alcohol and/or substance abuse in men versus women could suggest a differential impact of PTSD on risk for alcohol or substance use—and thus on the potential mediating role of PTSD in the relationship of childhood trauma and alcohol and substance use. In a review, Najavits, Weiss, and Shaw (1997) suggest that the comorbidity between PTSD and substance use disorders is more common in women than in men, though studies included in the review provide limited support. In contrast, two large epidemiological studies demonstrate increased comorbidity of PTSD and alcohol and substance use among men, relative to women (Kessler et al., 1995, Regier et al., 1990). Even so, in a nationally representative sample of adolescents, trauma was associated with increased risk for PTSD and substance use disorder comorbidity, but no effect of gender on risk for comorbidity was observed (Kilpatrick et al., 2003). Discrepancies of findings across studies may be due, at least in part, to methodological differences, such as the focus on one form of use disorder (e.g., alcohol abuse only or cocaine abuse only), on clinical vs. community samples, on different age groups, and on different racial/ethnic populations.
Importantly, African-American race is associated with less risk for substance use disorders, particularly when accounting for trauma (Kilpatrick et al., 2000, Kilpatrick et al., 2003), and other studies demonstrate increased alcohol abstinence in African-American men and women relative to white men and women (Caetano and Clark, 1998a, Caetano and Clark, 1998b). Additionally, despite other studies demonstrating increased risk for comorbidity in men, in a sample of African-American men and women substance abusers, psychiatric histories were comparable (Lundy, Gottheil, Serota, Weinstein, & Sterling, 1995). These differences highlight an area for further exploration and needed replication. If alcohol or substance use is experienced differently among African Americans, patterns of comorbidity—even by gender—may also differ. Furthermore, few studies examine whether PTSD mediates the relationship between childhood trauma and alcohol or substance abuse for African Americans. Epstein et al.’s (1998) findings were based on a largely white (85%) sample, though Chilcoat and Breslau's (1998) study was drawn from a larger sample (Breslau, Davis, Andreski, & Peterson, 1991) with more African-American participants (41.75%). No study has examined whether for African Americans the mediating role of PTSD on the relationship between childhood trauma and alcohol or substance use differs for men and women.
The goal of the current study was to examine the relationships among childhood trauma, current PTSD symptom frequency, and current problematic alcohol and substance use in a largely low-income, African-American sample of adult men and women. We hypothesized that these four variables of interest (childhood trauma, PTSD, problematic alcohol use, and problematic substance use) would be positively correlated with each other, and, based on the larger epidemiological studies (Kessler et al., 1995, Regier et al., 1990), that men would be more likely than women to meet criteria for PTSD comorbid with problematic alcohol or substance use. Furthermore, based on previous studies (e.g., Chilcoat & Breslau, 1998), we hypothesized that PTSD would mediate the relationship between childhood trauma and problematic alcohol use and, separately, between childhood trauma and problematic substance use. Our focus on childhood trauma—rather than other types of trauma—is based on theoretical and empirical models of the impact of early trauma on risk for addiction (De Bellis, 2002; Enoch et al., 2010). Finally, although Chaplin et al. (2008) and Jayawickreme et al.’s (2012) findings did not include childhood trauma, we hypothesized, based on the their results showing a stronger relationship in men between both PTSD-related and general negative mood/cognition and alcohol cravings that gender would moderate the effect of PTSD on the relationship between childhood trauma and problematic alcohol and substance use, such that the indirect effect of PTSD would be stronger in men than in women.
Section snippets
Participants and Procedure
Participants were adult individuals waiting in primary care, obstetrical–gynecological, and diabetes clinics of a large, public hospital in Atlanta, GA. Each participant was approached by a member of the research team and asked if s/he would be interested in study participation. Those who agreed to participate completed a battery of self-report measures, which took 45–75 min to complete (largely dependent on the extent of trauma history and symptoms). Due to variable literacy between subjects,
Data Analysis
Initial analyses included independent t-tests comparing men and women on CTQ, MPSS, AUDIT, and DAST continuous total scores, as well as bivariate correlations among these scores. In addition, a Pearson's χ2 examined categorically the rates of PTSD alone, alcohol and/or substance use problems alone, and PTSD comorbid with alcohol and/or substance use problems between men and women.
To examine whether PTSD symptoms mediate the relationship between childhood trauma and current problematic alcohol
Participant Characteristics
The resulting sample of complete cases yielded 2887 participants (803 men, 2084 women). Relative to participants whose data were incomplete (N = 8103), participants in the current study were younger, M = 39.55, SD = 13.41 vs. M = 40.17, SD = 13.96, t (5267.18) = 2.13, p < .05. No differences were observed for gender, race, income, CTQ, MPSS, AUDIT, or DAST.
The majority of participants in the current study (92.86%) were African-American. Nearly a third (31.97%) of participants reported a household monthly
Discussion
In our sample of primarily low-income, African-American participants recruited from outpatient primary care, diabetes, and OB/GYN clinics of an urban public hospital, we found that men were significantly more likely than women to report PTSD comorbid with problematic alcohol and/or substance use. Furthermore, we found that childhood trauma had a direct effect on current problematic alcohol use, as well as on current problematic substance use, but PTSD had a significant indirect effect on both
Conflicts of interest
We have no conflicts of interest to declare.
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We thank the Grady Trauma Project research staff and coordinators, Allen W. Graham and Angelo Brown, as well as the nurses in the Clinical Research Network of Grady Health Systems. This work was supported by funding from the National Institutes of Health (MH071537), the National Institute of Child Health and Human Development (MH018264), Howard Hughes Medical Institute, and the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR000454.