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. Author manuscript; available in PMC: 2026 Apr 28.
Published in final edited form as: J Anxiety Disord. 2021 Nov 6;85:102496. doi: 10.1016/j.janxdis.2021.102496

PTSD symptom heterogeneity and alcohol-related outcomes in U.S. military veterans: Indirect associations with coping strategies

Alexandra N Palmisano a,b,*, Sonya B Norman c,d,e,f, Kaitlyn E Panza c,f, Ismene L Petrakis a,b, Robert H Pietrzak a,b,g
PMCID: PMC13112779  NIHMSID: NIHMS2161198  PMID: 34775167

Abstract

Introduction:

This study investigated the role of coping strategies in mediating the relationship between the 7-factor model of posttraumatic stress disorder (PTSD) symptoms and alcohol misuse in veterans.

Methods:

Data were analyzed from 615 veterans from a nationally representative study of U.S. veterans who met criteria for probable full or subthreshold PTSD. Path analyses examined the role of self-sufficient, socially-supported, and avoidant coping strategies in mediating associations between PTSD symptom clusters and alcohol use disorder (AUD), alcohol consumption, and alcohol-related consequences.

Results:

Negative affect PTSD symptoms were associated with AUD through increased use of avoidant coping. Additionally, dysphoric arousal PTSD symptoms were associated with AUD; avoidant coping was associated with AUD and increased alcohol consumption; self-sufficient coping was associated with reduced AUD likelihood anhedonia symptoms with decreased use of self-sufficient coping; and negative affect with decreased use of socially-supported coping and increased use of avoidant coping.

Conclusions:

Results underscore the importance of avoidant coping strategies as potential mediators of the relation between PTSD symptoms and AUD. Interventions designed to mitigate engagement in avoidant coping strategies, and to bolster engagement in self-sufficient and socially-supported strategies may help reduce alcohol misuse in veterans with full or subthreshold PTSD.

Keywords: Posttraumatic stress disorder; Alcohol use disorder, Alcohol consumption; Alcohol consequences; Coping; Veterans

1. Introduction

Recent data from a U.S. veteran sample indicate that among those with alcohol use disorder (AUD), 20.3% meet criteria for posttraumatic stress disorder (PTSD), and that 16.8% of those with PTSD meet criteria for AUD (Norman, Haller, Hamblen, Southwick, & Pietrzak, 2018). Veterans with co-occurring PTSD and AUD exhibit reduced physical, mental, and cognitive functioning compared to those with either disorder alone (Blanco et al., 2013; Norman et al., 2018). Given the high prevalence and associated health effects of comorbid PTSD and AUD, elucidation of possible mechanisms that mediate this comorbidity may inform prevention and treatment approaches for these disorders.

Use of specific strategies to cope with the symptoms and related consequences of trauma may be a key factor in the maintenance and co-occurrence of PTSD and AUD (Feeny & Foa, 2006). A broad range of coping strategies have been identified (Carver, 1997), however, coping strategies are frequently conceptualized as two opposing factors—avoidant and approach coping. Avoidant coping is characterized by disengagement-based strategies that withdraw efforts from the stressor to manage problems and emotions. According to the self-medication hypothesis, individuals consume alcohol as an avoidant coping strategy to mitigate PTSD symptoms (Leeies, Pagura, Sareen, & Bolton, 2010). Consistent with this theory, studies in veterans have found that avoidant, drinking-to-cope motives mediate the respective associations between PTSD symptoms and hazardous drinking (McDevitt-Murphy, Luciano, Tripp, & Eddinger, 2017) and alcohol consequences (Miller, Pedersen, & Marshall, 2017).

In contrast to avoidant coping, approach coping is characterized by emotion- and problem-focused strategies that are oriented toward the stressor, which may be adaptive for individuals with PTSD and AUD. For example, greater reliance on approach coping than on avoidant coping has been shown to be associated with less alcohol consumption, fewer alcohol-related problems, and decreased psychiatric symptoms (Boden & Moos, 2009). Collectively, this body of research suggests that PTSD symptoms are associated with alcohol misuse through increased use of avoidant coping (Freeman, Jordan, & Madson, 2020; Grosso et al., 2014; Hruska, Fallon, Spoonster, Sledjeski, & Delahanty, 2011; Ménard & Arter, 2013; Ouimette, Finney, & Moos, 1999) and decreased use of approach coping strategies (Freeman et al., 2020; Grosso et al., 2014; McCabe, Mohr, Hammer, & Carlson, 2019; Ouimette et al., 1999).

While extant research has been vital in demonstrating the differential roles of avoidant and approach coping in mediating the relationship between PTSD and alcohol misuse, it has been argued that the approach-avoidance categorization may oversimplify the function of coping (Coyne & Racioppo, 2000; Skinner, Edge, Altman, & Sherwood, 2003). Moreover, existing studies examining the mediating effect of avoidant coping on the relation between PTSD symptoms and alcohol misuse have largely assessed the effect of a single “drinking-to-cope” measure drawn from more comprehensive assessments of coping strategies (Ullman, Relyea, Peter-Hagene, & Vasquez, 2013). This restrictive focus on single-item and two-order dimensions of coping may fail to capture the role of other coping strategies in mediating the relation between PTSD and alcohol misuse. Instead, a growing body of studies recommend assessing a broader array of three higher-order coping factors, including socially-supported, self-sufficient, and avoidant strategies (Gutiérrez, Peri, Torres, Caseras, & Valdés, 2007; Litman, 2006; Wang et al., 2018). Socially-supported and self-sufficient coping are defined by approach-oriented strategies that are respectively differentiated by coping with or without the aid of social support. Examples of socially-supported coping strategies include venting, and seeking emotional and instrumental social support. Self-sufficient coping includes strategies such as positive reinterpretation, humor, and acceptance. Avoidant coping, on the other hand, is characterized by strategies that withdraw efforts from the stressor, like diversionary thinking, denial, or substance use.

Extant studies are also limited in that they have largely examined PTSD as a homogenous disorder (i.e., overall PTSD symptom severity), which may not fully capture the heterogenous phenotypic expression of this disorder (Galatzer-Levy & Bryant, 2013). Examining the relationship between PTSD symptoms and alcohol misuse at a more nuanced level is supported by studies demonstrating that alcohol misuse may be driven by specific PTSD symptoms (Langdon et al., 2016; Walton et al., 2018). To characterize the dimensional structure of PTSD symptoms, a 7-factor hybrid model of PTSD was recently introduced. This model includes symptoms of intrusions, avoidance, negative affect, anhedonia, externalizing behaviors, anxious arousal, and dysphoric arousal (see Table 1 for symptom descriptions; Armour et al., 2015). The 7-factor model has been found to be the best-fitting structural model of PTSD across a number of diverse samples (Armour, Contractor, Shea, Elhai, & Pietrzak, 2016; Seligowski & Orcutt, 2016), including veterans (Pietrzak et al., 2015; Wortmann et al., 2016), and has been found to provide optimal fit for both self-report (Weathers, 2013) and clinician-administered (Weathers et al., 2018) measures of PTSD symptoms (Lee et al., 2019). Given studies demonstrating differential associations between more refined PTSD symptom factors and aspects of functioning (i.e. externalizing behaviors, negative affect, and anhedonia and suicidal ideation (Pietrzak et al., 2015)), use of the 7-factor PTSD symptom model may provide greater specificity in elucidating important associations with key clinical and functional outcomes in trauma survivors.

Table 1.

Symptoms for each factor of the 7-factor hybrid model of PTSD.

Factors Symptom items
Intrusions Intrusive thoughts, nightmares, flashbacks, emotional cue reactivity, physiological cue reactivity
Avoidance Avoidance of trauma-related thoughts and reminders
Negative affect Trauma-related amnesia, negative beliefs, blame of self or others, negative trauma-related emotions
Anhedonia Loss of interest, detachment, restricted affect
Externalizing behaviors Irritability/anger, self-destructive/reckless behavior
Anxious arousal Hypervigilance, exaggerated startle response
Dysphoric arousal Difficulty concentrating, sleep disturbance
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To date, only two studies to our knowledge have utilized this 7-factor model of PTSD symptoms to examine the relationship between PTSD symptoms and alcohol misuse in veterans (Claycomb Erwin et al., 2017; Palmisano, Fogle, Tsai, Petrakis, & Pietrzak, 2021). Results of these studies suggest that externalizing behaviors, dysphoric arousal, and anxious arousal symptoms are positively associated with AUD in veterans who screened positive for PTSD (Palmisano et al., 2021), while dysphoric arousal, negative affect, and anhedonia are positively associated with past-year alcohol consequences in trauma-exposed veterans (Claycomb Erwin et al., 2017); no significant associations were found between any PTSD symptom factor and alcohol consumption (Claycomb Erwin et al., 2017). These studies highlight the importance of dissociating measures of alcohol misuse into separate constructs of AUD, consumption, and consequences. A notable limitation of these studies, however, is that neither investigated the potential role of coping on the indirect relations between distinct PTSD symptom clusters and these alcohol-related outcomes. Such data may help inform potential mechanisms that underlie these associations as well as identify modifiable targets for prevention and treatment efforts for these disorders.

To address this gap, we analyzed data from the 2019–2020 National Health and Resilience in Veterans Study (NHRVS) to evaluate indirect associations between 7-factor PTSD symptoms and AUD, alcohol consumption, and alcohol-related consequences through self-sufficient, socially-supported, and avoidant coping in veterans who screened positive for probable full or subthreshold PTSD. Based on prior work (Claycomb Erwin et al., 2017; Palmisano et al., 2021), we hypothesized that externalizing behaviors and dysphoric arousal PTSD symptoms would be associated with increased likelihood of AUD, and that dysphoric arousal, negative affect, and anhedonia would be associated with increased alcohol-related consequences. Moreover, we hypothesized that the positive associations between these PTSD symptom clusters and alcohol-related outcomes would be indirectly associated with greater use of avoidant coping and less use of self-sufficient and socially-supported coping strategies (Freeman et al., 2020; Grosso et al., 2014). Path models depicting direct and indirect relationships between PTSD symptom clusters hypothesized to affect the alcohol-related outcomes through coping strategies are presented in Figs. 1 and 2 in Supplemental Materials.

2. Material and Methods

2.1. Participants and Procedure

The National Health and Resilience in Veterans Study (NHRVS) is a nationally representative survey of 4069 U.S. veterans that was conducted between 11/18/19 and 3/8/2020 (median completion date: 11/21/2019). Data from each participant was collected at a single time point. The sample was ascertained from KnowledgePanel®, a research panel of more than 50,000 households maintained by the survey firm Ipsos that represents approximately 98% of U.S. adults based on an address-based sample frame from the U.S. Postal Service’s Delivery Sequence File. Missing item-level PCL-5 and AUDIT data (< 5%) were imputed using an iterative Markov chain Monte Carlo (MCMC) method. To permit generalizability of study results to the entire population of U. S. veterans, the Ipsos statistical team computed post-stratification weights based on demographic distributions from the most recent Veterans Supplement of the U.S. Census Bureau’s Current Population Survey (United States Bureau of the Census, 2019). An iterative proportional fitting procedure was used to generate the final post-stratification weights. All participants provided informed consent and the study was approved by the Human Subjects Committee of the VA Connecticut Healthcare System.

2.2. Assessments

Table 2 provides detailed descriptions of the assessments used to assess study variables.

Table 2.

Descriptions of assessments used to assess study variables.

Variable Assessment Description
Trauma history The Life-Events Checklist for DSM-5 (LEC-5;Weathers & Litz B.T, 2013) was used to screen for lifetime exposure to 16 potentially traumatic events, and one item assessed any other extraordinarily stressful event not captured in the first 16 items. The total number of potentially traumatic events endorsed was summed to yield a measure of the number of lifetime traumas.
PTSD symptoms The PTSD Checklist for DSM-5 (PCL-5) was used to assess PTSD symptoms in relation to veterans’ ‘worst’ event endorsed on the LEC-5. The following two questions were added to assess Criterion F (duration) and G (functional significance): “How long did these reactions last?” and “Did these reactions cause you distress or result in a failure to fulfill obligations at home, work, or school?” Endorsement of ‘moderate’ or greater on the Criterion G question was considered a positive endorsement. Following prior work (McLaughlin et al., 2015; Mota et al., 2016), PCL-5 responses were used to create a three-group variable: a) no/low PTSD symptoms (defined as endorsement of ≤1 PTSD criteria B-E at a severity of “moderate” or higher); b) probable subthreshold DSM-5 PTSD (defined as endorsement of 2 or 3 B-E criteria, or all 4 B-E criteria, but not 1 month symptom duration and/or functional impairment); and c) probable full DSM-5 PTSD (defined as meeting criteria A-G for PTSD). Items were summed to yield measures of severity for each symptom cluster of the 7-factor model (intrusionsα =0.86; avoidanceα =0.81; negative affectα =0.85; anhedoniaα =0.80; externalizing behaviorsα =0.61; anxious arousalα =0.74; dysphoric arousalα =0.61). Participants who denied any trauma exposure on the LEC-5 were not administered the PCL-5.
AUD, alcohol consumption, and alcohol-related consequences The 10-item Alcohol Use Disorders Identification Test (AUDIT;Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) assessed past-year probable AUD, alcohol consumption, and consequences (AUDα =0.89; AUDIT-Cα=0.82; AUDIT-CQα=0.87). A three-factor solution has been found to be the best-fitting structural model of the AUDIT and each factor evidences good internal consistency and test-retest reliability (Doyle, Donovan, & Kivlahan, 2007; Hallinan, McGilloway, Dempster, & Donnelly, 2011; Maisto, Conigliaro, McNeil, Kraemer, & Kelley, 2000; Shevlin & Smith, 2007; Wade, Varker, O’Donnell, & Forbes, 2012). Moreover, several systematic reviews have found the AUDIT to be psychometrically sensitive and suitable to screen for AUD diagnoses in diverse populations, including veterans (Babor & Robaina, 2016; de Meneses-Gaya, Zuardi, Loureiro, & Crippa, 2009; Reinert & Allen, 2002, 2007). A score of ≥ 8 was indicative of probable current AUD given its diagnostic proficiency in screening for AUD in nationally-representative veteran samples (Babor & Robaina, 2016; Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998; Crawford et al., 2013).
Coping strategies A modified version of the Brief COPE (B-COPE;Carver, 1997) was used to assess coping strategies. Participants were provided a list of 14 coping strategies and examples of each, and were asked to “Please select THREE coping strategies below that you most commonly use to deal with symptoms related to your worst traumatic event.” This method of assessing coping strategies is consistent with several recent studies that successfully used this modified version of the B-COPE measure in the NHRVS (Contractor, Armour, Shea, Mota, & Pietrzak, 2016; Levy, Chung, Slade, Van Ness, & Pietrzak, 2019; Straus, Norman, Tripp, Pitts, & Pietrzak, 2019; Whealin et al., 2020). The B-COPE scale from which this measure was derived evidences good convergent and discriminant validity (Carver, 1997; Meyer, 2001). Following work by Litman (2006), three subscales were created from the 14 coping strategies, including self-sufficient, socially-supported, and avoidant coping. Self-sufficient coping included a sum of endorsements of the following coping strategies: Planning, Active Coping, Positive Reframing, Acceptance, Humor, and Religion. Socially-supported coping included a sum of endorsements of the following strategies: Use of Emotional Support, Use of Instrumental Support, and Venting. Avoidant coping included a sum of endorsements of the following strategies: Self-Distraction, Denial, Substance Use, Behavioral Disengagement, and Self-Blame.
Depressive symptoms Past two-week depressive symptoms were assessed using The Patient Health Questionnaire-2 (PHQ-2;Kroenke, Spitzer, & Williams, 2003). Items were summed to quantify the severity of current depressive symptoms (α = 0.87).
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Trauma history.

The Life-Events Checklist for DSM-5 (LEC-5; Weathers & Litz B.T, 2013) was used to screen for lifetime exposure to potentially traumatic events.

PTSD symptoms.

The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers, 2013) was used to assess probable past-month DSM-5 PTSD symptoms and yield measures of severity for each symptom of the 7-factor model. Table 2 provides a detailed explanation of the operationalization of probable full and subthreshold PTSD.

AUD, alcohol consumption, and alcohol-related consequences.

The 10-item Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993; Wade et al., 2012) was used to assess probable past-year AUD, alcohol consumption, and consequences. A score of ≥ 8 was indicative of probable current AUD given its diagnostic proficiency in screening for AUD in nationally-representative veteran samples (Babor & Robaina, 2016; Bush et al., 1998; Crawford et al., 2013).

Coping strategies.

A modified version of the Brief COPE (B-COPE; Carver, 1997) was used to assess coping strategies.

Depressive symptoms.

Past two-week depressive symptoms were assessed using The Patient Health Questionnaire-2 (PHQ-2; Kroenke et al., 2003).

2.3. Data Analysis

Descriptive statistics and correlational analyses were conducted using SPSS Version 27 (IBM, 2020). Bootstrapped path analyses (10,000 samples) were conducted among veterans who screened positive for probable full or subthreshold PTSD using Mplus version 7.11 (Muthén & Muthén, 1998) to evaluate indirect associations between the 7-factor PTSD symptom model and AUD, alcohol consumption, and consequences through self-sufficient, socially-supported, and avoidant coping. Two models were conducted, both of which adjusted for age, gender, and severity of depressive symptoms. These covariates were selected a priori based on their association with PTSD and alcohol misuse prevalence (Norman et al., 2018).

The first model used weighted least squares estimation (WLS) to examine indirect associations between the 7-factor model and AUD through self-sufficient, socially-supported, and avoidant coping. The second model used maximum likelihood estimation with robust standard errors (MLR) to examine indirect associations between the 7-factor model and both alcohol consumption and alcohol-related consequences through self-sufficient, socially-supported, and avoidant coping. Separate models were conducted to account for the different estimators needed for dichotomous (AUD) and continuous measures (alcohol consumption and alcohol-related consequences) and all indirect paths were specified. In each model, coping strategies were simultaneously tested, factors were allowed to correlate, all error covariances were fixed to zero, and all tests were two-tailed. Planned post-hoc ANOVA analyses were then conducted to identify specific coping strategies that drove the significant associations with the alcohol-related outcomes. Corrections were made for multiple comparisons.

3. Results

3.1. Descriptive statistics

Of the 4069 veterans who participated in the NHRVS, 167 (5.1%) screened positive for probable past-month full PTSD, 448 (11.4%) met criteria for probable past-month subthreshold PTSD, and 360 (10.5%) screened positive for probable past-year AUD. Of the 615 veterans with probable full (30.7%) or subthreshold (69.3%) PTSD that were included in the path analyses, 99 (19.2%) screened positive for AUD, most were male (81.1%) and white, non-Hispanic (71.4%), with a mean age of 54.5 years (SD=15.1). A total 64.4% of the sample reported being married or partnered, 29.3% had completed a bachelor’s degree or higher level of education, and 52.5% reported household incomes of 60,000 USD or greater. A total 49.8% of the sample served in the Army, 20.4% in the Navy, 14.4% in the Air Force, 7.3% in the Marine Corp, and 8.1% in the National Guard, Reserves, or Coast Guard with 40.9% spending 10 + years in the military; approximately half of the sample were combat veterans (46.5%). On average, participants endorsed 13.8 (SD=10.7, range=1–56) potentially traumatic events, including 5.1 (SD=2.8; range=0–15) direct, 3.6 (SD=3.4; range=0–16) witnessed, 3.4 (SD=4.5; range=0–17) learned about, and 1.7 (SD=3.4; range=0–17) part of job exposures. The most common index traumas endorsed included combat (18.0%), sexual assault (10.5%), transportation accident (8.7%), physical assault (7.9%), and sudden accidental death (6.9%).

Table 3 shows descriptive statistics and correlations among observed variables. Externalizing behaviors and dysphoric arousal symptom clusters were positively correlated with all three alcohol-related outcomes. Negative affect and anhedonia symptom clusters were positively correlated with consequences. PTSD intrusion, avoidance, and anxious arousal symptom clusters were not associated with AUD, alcohol consumption, or alcohol-related consequences. Use of self-sufficient coping was negatively correlated with all three alcohol-related outcomes, while socially-supported coping was negatively correlated with consequences. Avoidant coping was positively correlated with all three alcohol-related outcomes.

Table 3.

Means, standard deviations, and bivariate correlations among observed variables in veterans with full or subthreshold PTSD (n = 615).

Variable N (weighted %) or Mean (SD) AUD AUDIT-Consumption AUDIT-Consequences
Age 54.5 (15.1) −0.16 * ** −0.18 * ** −0.19 * **
Male sex 461 (81.1%) 0.04 0.03 0.07
Total PHQ-2 scorea 2.1 (1.9) 0.16 * ** 0.12 * * 0.19 * **
Total PCL-5 scoreb 31.1 (15.8) 0.05 0.06 0.13 * **
AUD 99 (16.1%) – 0.75 * ** 0.76 * **
AUDIT-Consumptionc 2.7 (3.0) 0.75 * ** – 0.65 * **
AUDIT-Consequencesd 1.5 (4.1) 0.76 * ** 0.65 * ** –
Intrusions 6.9 (4.8) 0.01 −0.01 0.07
Avoidance 3.7 (2.4) −0.07 −0.07 −0.03
Negative affect 5.8 (4.2) 0.03 0.06 0.12 * *
Anhedonia 5.1 (3.4) 0.06 0.06 0.14 * **
Externalizing behaviors 2.3 (2.1) 0.12 * ** 0.10 * * 0.17 * **
Anxious arousal 3.6 (2.5) −0.001 0.04 −0.01
Dysphoric arousal 3.7 (2.3) 0.17 * ** 0.14 * ** 0.19 * **
Self-sufficient copinge 1.5 (0.8) −0.16 * ** −0.10 * * −0.19 * **
Socially-supported copinge 0.7 (0.7) −0.04 −0.06 −0.12 * *
Avoidant copinge 0.7 (0.8) 0.18 * ** 0.18 * ** 0.25 * **
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Note: Results adjusted for age, gender, and depressive symptom severity; SD = standard deviation; PHQ-2 = Patient Health Questionnaire-2; PCL-5 = Posttraumatic Stress Disorder Checklist for DSM-5; AUD = Alcohol use disorder; AUDIT = Alcohol Use Disorders Identification Test

*

p ≤ 0.01,

* *

p ≤ 0.001,

* **

p ≤ 0.0001

a

PHQ-2 scores ranged from 0 to 6 with higher scores reflecting greater depressive symptom severity

b

Total PCL-5 scores ranged from 0 to 80 with higher scores reflecting greater PTSD symptom severity

c

AUDIT-consumption scores ranged from 0 to 12 with higher score reflecting greater alcohol consumption

d

AUDIT-consequences scores ranged from 0 to 28 with higher score reflecting greater alcohol-related consequences

e

Higher scores reflect greater number of endorsements of this particular coping strategy

3.2. Alcohol use disorder

Significant paths from the model are presented in Fig. 1. Standardized coefficients and standard errors of the direct relations between PTSD symptom clusters on coping strategies are presented in Table 4. Standardized coefficients and standard errors of the direct and indirect relations between PTSD symptom clusters on AUD through coping strategies are presented in Table 5.

Fig. 1.

Fig. 1.

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Significant paths of the model with standardized coefficients for the direct and indirect effects of PTSD symptom clusters on alcohol use disorder through coping strategies. To improve model parsimony, nonsignificant pathways in the initial model solution were excluded from the final model shown. Dysphoric arousal, self-sufficient coping, and avoidant coping were each directly associated with AUD. Negative affect symptoms were directly associated with socially-supported coping and avoidant coping strategies. Negative affect symptoms were indirectly associated with AUD through avoidant coping. The indirect effect estimate was derived from the product of the two paths along the mediation route. Note: Model shows results when the ‘Substance Use’ coping strategy was included in the avoidant coping factor. AUD = Alcohol use disorder; * p ≤ 0.05, * * p ≤ 0.01, * ** p ≤ 0.001.

Table 4.

Direct Effects of 7-Factor Hybrid PTSD Symptoms on Coping Subscales.

Self-sufficient coping
 Socially-supported coping
 Avoidant coping
Independent Variable β SE p β SE p β SE p
Model 1 (AUD) Intrusions −0.01 0.02 0.55 0.02 0.01 0.09 −0.01 0.01 0.24
Avoidance 0.03 0.02 0.23 −0.02 0.02 0.36 −0.01 0.02 0.62
Negative Affect −0.02 0.02 0.21 −0.03 0.01 0.04 0.06 0.01 0.00
Anhedonia −0.02 0.02 0.19 −0.00 0.02 0.93 0.01 0.02 0.62
Externalizing Behaviors −0.00 0.03 0.96 −0.04 0.03 0.14 0.05 0.03 0.08
Anxious Arousal 0.00 0.02 0.86 0.01 0.02 0.46 −0.00 0.02 0.83
Dysphoric Arousal 0.01 0.03 0.69 −0.01 0.02 0.74 −0.01 0.02 0.62
Model 2 (Consumption and Consequences) Intrusions −0.05 0.07 0.47 0.12 0.07 0.09 −0.08 0.08 0.30
Avoidance 0.06 0.06 0.29 −0.04 0.06 0.54 −0.04 0.05 0.48
Negative Affect −0.10 0.06 0.11 −0.14 0.07 0.04 0.30 0.06 0.00
Anhedonia −0.17 0.07 0.02 0.07 0.07 0.36 0.08 0.06 0.20
Externalizing Behaviors 0.01 0.08 0.88 −0.13 0.08 0.08 0.12 0.08 0.11
Anxious Arousal 0.01 0.06 0.83 0.05 0.06 0.46 −0.01 0.06 0.83
Dysphoric Arousal 0.01 0.07 0.85 −0.01 0.06 0.93 −0.03 0.07 0.65
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Direct effects of the 7-factor PTSD symptoms on each of the coping subscales for each path model (Model 1: AUD; Model 2: Consumption and Consequences).

Table 5.

Summary of Path Model Predicting Alcohol Use Disorder (AUD).

AUD
Independent Variable (IV) Mediating Variable β SE p
Intrusions −0.01 0.03 0.66
Intrusions Self-sufficient coping 0.00 0.00 0.57
Intrusions Socially-supported coping −0.00 0.00 0.57
Intrusions Avoidant coping −0.01 0.00 0.26
Avoidance −0.05 0.05 0.28
Avoidance Self-sufficient coping −0.01 0.01 0.27
Avoidance Socially-supported coping 0.00 0.00 0.62
Avoidance Avoidant coping −0.00 −0.01 0.63
Negative affect −0.03 0.03 0.25
Negative affect Self-sufficient coping 0.01 0.00 0.21
Negative affect Socially-supported coping 0.00 0.00 0.56
Negative affect Avoidant coping 0.02 0.01 0.01
Anhedonia −0.05 0.03 0.13
Anhedonia Self-sufficient coping 0.01 0.01 0.22
Anhedonia Socially-supported coping 0.00 0.00 0.93
Anhedonia Avoidant coping 0.00 0.01 0.63
Externalizing behaviors 0.06 0.06 0.30
Externalizing behaviors Self-sufficient coping 0.00 0.01 0.96
Externalizing behaviors Socially-supported coping 0.00 0.00 0.60
Externalizing behaviors Avoidant coping 0.02 0.01 0.12
Anxious arousal −0.04 0.04 0.28
Anxious arousal Self-sufficient coping −0.00 0.01 0.86
Anxious arousal Socially-supported coping −0.00 0.00 0.66
Anxious arousal Avoidant coping −0.00 0.00 0.84
Dysphoric arousal 0.12 0.05 0.02
Dysphoric arousal Self-sufficient coping −0.00 0.00 0.68
Dysphoric arousal Socially-supported coping 0.00 0.00 0.77
Dysphoric arousal Avoidant coping −0.00 0.01 0.62
Self-sufficient coping −0.29 0.10 0.01
Socially-supported coping −0.06 0.11 0.56
Avoidant coping 0.35 0.10 0.00
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Direct effects of 7-factor PTSD symptom clusters on AUD, and indirect effects of 7-factor PTSD symptom clusters on AUD through self-sufficient, socially-supported, and avoidant coping.

PTSD dysphoric arousal symptoms were associated with greater likelihood of AUD (Table 5; Fig. 1). Avoidant coping was also associated with greater likelihood of AUD, while self-sufficient coping was associated with decreased likelihood of AUD (Table 5; Fig. 1). Examining direct associations between PTSD symptoms and coping strategies, negative affect symptoms were associated with greater use of avoidant coping strategies and less use of socially-supported strategies (Table 4; Fig. 1).

With regard to indirect effects, an association between negative affect symptoms and likelihood of AUD via avoidant coping was observed, such that negative affect was associated with increased engagement in avoidant coping, which was in turn associated with increased likelihood of AUD (Table 5; Fig. 1). It is important to note that the ‘Substance Use’ coping strategy of the B-COPE measure was included in the avoidant coping subscale to assess the effect of any substance-related coping on the relationship between PTSD symptoms and alcohol-related outcomes. To examine whether the observed association between negative affect and likelihood of AUD through avoidant coping was an artifact of potential construct overlap between the substance use coping strategy and AUD, post-hoc analyses were conducted examining the specific coping strategies that drove this indirect effect. Findings revealed that no individual avoidant coping strategies drove this association (p’s > 0.11), suggesting that negative affect PTSD symptoms are associated with increased likelihood of AUD via a general propensity to use avoidant coping strategies.

The relationships proposed in the original model explained 25.8% of the variance in AUD, 2.9% of the variance in self-sufficient coping, 4.3% of the variance in socially-supported coping, and 12.4% of the variance in avoidant coping.

3.3. Alcohol consumption and consequences

Significant paths from the model are presented in Fig. 2. Standardized coefficients and standard errors of the direct relations between PTSD symptom clusters on coping strategies are presented in Table 4. Standardized coefficients and standard errors of the direct and indirect relations between PTSD symptom clusters on alcohol consumption and consequences through coping strategies are presented in Table 6.

Fig. 2.

Fig. 2.

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Significant paths of the model with standardized coefficients for the direct and indirect effects of PTSD symptom clusters on alcohol consumption through coping strategies. To improve model parsimony, nonsignificant pathways in the initial model solution were excluded from the final model shown. Anhedonia was directly associated with self-sufficient coping. Negative affect was directly associated with socially-supported coping and avoidant coping strategies. Avoidant coping was directly associated with alcohol consumption. No significant indirect effects were found. Note: Model shows results when the ‘Substance Use’ coping strategy was included in the avoidant coping factor. * p ≤ 0.05, * * p ≤ 0.01, * ** p ≤ 0.001.

Table 6.

Summary of Path Model Predicting Alcohol Consumption and Alcohol-Related Consequences.

AUDIT-Consumption
 AUDIT-Consequences
Independent Variable (IV) Mediating Variable β SE p β SE p
Intrusions −0.08 0.75 0.28 0.00 0.08 0.96
Intrusions Self-sufficient coping −0.00 0.01 0.86 0.01 0.02 0.52
Intrusions Socially-supported coping 0.00 0.01 0.81 −0.03 0.02 0.23
Intrusions Avoidant coping −0.08 0.02 0.35 0.00 0.02 0.91
Avoidance −0.10 0.06 0.11 −0.06 0.06 0.31
Avoidance Self-sufficient coping 0.00 0.01 0.86 −0.02 0.02 0.36
Avoidance Socially-supported coping −0.00 0.00 0.81 0.01 0.02 0.58
Avoidance Avoidant coping −0.01 0.01 0.52 0.00 0.01 0.91
Negative affect −0.00 0.06 0.98 −0.01 0.07 0.90
Negative affect Self-sufficient coping −0.00 0.01 0.85 0.03 0.03 0.26
Negative affect Socially-supported coping −0.00 0.01 0.80 0.03 0.03 0.23
Negative affect Avoidant coping 0.06 0.03 0.07 −0.01 0.07 0.91
Anhedonia −0.08 0.08 0.31 −0.06 0.06 0.36
Anhedonia Self-sufficient coping −0.00 0.02 0.85 0.05 0.03 0.15
Anhedonia Socially-supported coping 0.00 0.01 0.79 −0.02 0.02 0.45
Anhedonia Avoidant coping 0.02 0.02 0.29 −0.00 0.02 0.91
Externalizing behaviors 0.03 0.08 0.67 0.09 0.08 0.28
Externalizing behaviors Self-sufficient coping 0.00 0.00 0.91 −0.00 0.02 0.89
Externalizing behaviors Socially-supported coping −0.00 0.01 0.80 0.03 0.03 0.25
Externalizing behaviors Avoidant coping 0.03 0.02 0.22 −0.00 0.03 0.91
Anxious arousal 0.02 0.07 0.80 −0.10 0.08 0.17
Anxious arousal Self-sufficient coping 0.00 0.00 0.89 −0.00 0.02 0.83
Anxious arousal Socially-supported coping 0.00 0.00 0.80 −0.01 0.02 0.54
Anxious arousal Avoidant coping −0.00 0.01 0.84 0.00 0.00 0.91
Dysphoric arousal 0.15 0.08 0.08 0.13 0.09 0.14
Dysphoric arousal Self-sufficient coping 0.00 0.00 0.90 −0.00 0.02 0.85
Dysphoric arousal Socially-supported coping 0.00 0.00 0.93 0.00 0.02 0.93
Dysphoric arousal Avoidant coping −0.01 0.01 0.65 0.13 0.09 0.14
Self-sufficient coping 0.02 0.10 0.85 −0.29 0.17 0.09
Socially-supported coping 0.02 0.09 080 −0.24 0.16 0.13
Avoidant coping 0.20 0.10 0.05 −0.02 0.22 0.91
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Direct effects of 7-factor PTSD symptom clusters on alcohol consumption and alcohol-related consequences, and indirect effects of 7-factor PTSD symptom clusters on these outcomes through self-sufficient, socially-supported, and avoidant coping.

None of the PTSD symptom clusters were directly associated with alcohol consumption or alcohol-related consequences, respectively (Table 6); however, avoidant coping was directly associated with increased alcohol consumption (Table 6; Fig. 2). Significant direct associations between PTSD symptom clusters and coping strategies were also found. Specifically, anhedonia symptoms were directly associated with less use of self-sufficient coping, while negative affect symptoms were associated with less use of socially-supported coping and increased use of avoidant coping (Table 4; Fig. 2).

No significant indirect effects of coping strategies were found on the relationship between any PTSD symptom cluster and alcohol consumption or alcohol-related consequences, respectively (Table 6).

The relationships proposed in the original model explained 11.0% of the variance in alcohol consumption, 23.0% of the variance in alcohol-related consequences, 5.2% of the variance in self-sufficient coping, 2.9% of the variance in socially-supported coping, and 13.1% of the variance in avoidant coping.

4. Discussion

This study evaluated the role of coping strategies in mediating associations between the 7-factor PTSD symptom model, and AUD, alcohol consumption, and alcohol-related consequences in a contemporary, nationally representative cohort of U.S. military veterans who screened positive for full or subthreshold PTSD.

Results revealed that negative affect PTSD symptoms were associated with increased likelihood of AUD through increased use of avoidant coping strategies. Results further revealed that (1) dysphoric arousal PTSD symptoms were associated with increased likelihood of AUD, (2) avoidant coping was independently associated with increased AUD likelihood and increased alcohol consumption, (3) self-sufficient coping was associated with reduced AUD likelihood, (4) anhedonia symptoms were associated with decreased use of self-sufficient coping, and (5) negative affect was associated with decreased use of socially-supported coping and increased use of avoidant coping. No significant indirect effects of any coping strategy were found on the association between any PTSD symptom cluster and alcohol consumption. Similarly, no significant indirect effects of any coping strategy were found on the association between any PTSD symptom cluster and alcohol-related consequences. The results partially support our hypotheses that dysphoric arousal would be associated with increased likelihood of AUD, and that PTSD symptom clusters would be positively associated with alcohol-related outcomes through greater use of avoidant coping strategies and decreased use of self-sufficient and socially-supported coping strategies.

Consistent with past research demonstrating that PTSD symptoms are related to alcohol misuse through avoidant coping (Freeman et al., 2020; Grosso et al., 2014; Meénard & Arter, 2013; Ouimette et al., 1999), we found that negative affect PTSD symptoms were indirectly associated with likelihood of AUD via engagement in avoidant coping strategies. Disentangling the role of specific avoidant coping strategies on this indirect relation revealed that no specific avoidant coping strategy drove the association between negative affect and AUD likelihood. Therefore, in addition to using substances to cope, a more general tendency to employ avoidant coping strategies (i.e. self-distraction, denial, behavioral disengagement, and self-blame) may underlie the link between negative affect PTSD symptoms and AUD. These findings support the self-medication hypothesis, which posits that individuals use avoidant coping strategies to regulate distressing PTSD symptoms, which may subsequently lead to increased alcohol consumption and dependence (Leeies et al., 2010). These findings are novel and suggest targets for intervention. Of note, adjustment for depressive symptoms in our models increases confidence that the demonstrated associations between distinct PTSD symptoms, avoidant coping, and the alcohol-related outcomes are not an artifact of potential construct overlap between PTSD and broader elevations in internalizing symptoms, but instead represent a PTSD-specific self-medication mechanism.

The finding that dysphoric arousal symptoms (i.e. difficulty concentrating, sleep disturbances) were associated with increased likelihood of AUD is consistent with that of previous research which found that dysphoric arousal symptoms explained 20.7% of the variance in AUD in a sample of trauma-exposed veterans and 12.4% of the variance in AUD in veterans who screened positive for PTSD (Palmisano et al., 2021). Substantial research has demonstrated an association between PTSD and sleep disturbances in veterans (Lamarche & De Koninck, 2007), and sleep problems have been shown to significantly impair other aspects of physical (Clum, Nishith, & Resick, 2001) and mental functioning (DeGutis et al., 2018), including concentration (Wang et al., 2021). Moreover, PTSD-related sleep difficulties have been found to be associated with drinking-to-cope motives (Nishith, Resick, & Mueser, 2001), suggesting that trauma-exposed veterans with dysphoric arousal symptoms may consume alcohol for its sedative hypnotic properties to promote sleep (Vitiello, 1997). Notably, our results are consistent with past research that has differentiated dysphoric and anxious arousal symptoms in relation to AUD (Armour et al., 2012; Claycomb Erwin et al., 2017; Palmisano et al., 2021; Pietrzak et al., 2015; Tsai et al., 2015). Thus, the 7-factor model of PTSD may better inform assessment and treatment of AUD.

As expected, socially-supported coping strategies were correlated with reduced alcohol-related consequences, and self-sufficient coping was correlated with reduced alcohol consumption and reduced likelihood of AUD. Moreover, greater engagement in self-sufficient coping was directly associated with reduced AUD likelihood. These findings support previous studies that have found that greater reliance on approach coping than on avoidant coping is associated with less alcohol consumption, fewer alcohol-related problems, and decreased psychiatric symptoms (Boden & Moos, 2009; Freeman et al., 2020; Grosso et al., 2014; McCabe et al., 2019; Ouimette et al., 1999). However, no indirect associations between socially-supported or self-sufficient coping were observed with any alcohol-related outcome. The absence of significant indirect relations may be due to the finding that greater PTSD symptoms were associated with a reduced likelihood of engaging these more adaptive coping strategies, thus limiting their ability to help buffer against alcohol-related outcomes. Specifically, anhedonia symptoms were associated with less use of socially-supported coping and negative affect symptoms were associated with less use of self-sufficient coping. While a large body of literature has examined the influence of avoidant coping on the indirect relation between PTSD symptoms and alcohol misuse, relatively little research has examined the role of more adaptive forms of coping, and the existing literature fails to distinguish between socially-supported and self-sufficient coping. Thus, further research evaluating the relative impact of various coping strategies on these relations is warranted.

Consistent with previous findings by Claycomb Erwin et al. (2017), no direct relations between any PTSD symptom cluster and alcohol consumption was observed. Extending upon previous findings, however, we found that negative affect symptoms were directly associated with increased avoidant coping, and that avoidant coping was directly associated with increased alcohol consumption. While cross-sectional data precludes us from inferring temporal, causal associations between PTSD symptom clusters and alcohol misuse, our results again support the notion that may veterans use alcohol to dampen the intensity of their PTSD symptoms.

This study has some methodological limitations. Despite being well-validated, self-report assessments were used to measure PTSD symptom severity, alcohol-related outcomes, and coping strategies; therefore, reporting bias cannot be discounted. Future studies may benefit from the use of structured clinical interviews to avoid potential social desirability effects. Second, while extensive systematic reviews have found the AUDIT to be psychometrically suitable to screen for AUD diagnoses (Reinert & Allen, 2007), further research using diagnostic tools is needed to replicate our findings. Third, our sample was comprised predominantly of older white men (~75%), which may limit generalizability of findings to younger veterans, non-veterans, more racially and ethnically diverse individuals, and female veterans. The over-representation of male veterans is particularly notable given that female veterans have a higher prevalence of PTSD than male veterans (Lehavot, Katon, Chen, Fortney, & Simpson, 2018), and that AUD and alcohol misuse are more prevalent among males than their female counterparts (Maguen, Ren, Bosch, Marmar, & Seal, 2010; Street, Gradus, Giasson, Vogt, & Resick, 2013). Moreover, coping strategies have been shown to differ by age, race, and gender. For example, it has been found that younger service members are more likely to use emotional support coping than older service members (Rice & Liu, 2016), that African Americans are more likely to use problem solving and avoidant coping than Whites (Weiss et al., 2017), and that women are more likely than men to seek social support (Tamres, Janicki, & Helgeson, 2002) and use self-blame, denial, and positive reframing coping strategies (Schmied et al., 2015). Finally, our findings are cross-sectional, precluding the ability to draw causal, temporal conclusions. Therefore, longitudinal or event-related investigations of association between PTSD symptoms, coping strategies, and alcohol-related outcomes are warranted.

Despite these limitations, results of this study provide a novel contribution to extant literature by assessing a more comprehensive array of coping strategies on the indirect relations between PTSD symptoms and alcohol-related outcomes. These models are the first to use the contemporary 7-factor structural model of PTSD symptoms to examine these relations at the symptom level. Our findings emphasize the importance of assessing coping strategies in trauma-exposed individuals with PTSD symptoms, since avoidant coping strategies may be linked to increased risk for AUD, alcohol consumption, and alcohol-related consequences, while self-sufficient and socially-supported coping strategies may help buffer against these outcomes. Additionally, our findings suggest that coping strategies may serve as modifiable treatment targets in interventions designed to reduce avoidant coping and promote approach-oriented strategies since these targets may be crucial in helping reduce alcohol misuse in individuals with PTSD symptoms. This suggestion aligns with VA/DoD clinical practice guidelines (Department of Veterans Affairs/Department of Defense, 2017; Hamblen et al., 2019), which recommend trauma-focused interventions, such as prolonged exposure (Foa, Hembree, & Rothbaum, 2007) and cognitive processing therapy (Resick, 2001), as first-line interventions for individuals with PTSD and AUD. These interventions help individuals process their traumatic memories by challenging avoidant coping and promoting self-sufficient and socially-supported coping strategies and have been shown to be effective at reducing PTSD symptoms and alcohol misuse (Back et al., 2019; Norman et al., 2019; Petrakis et al., 2020; Roberts, Roberts, Jones, & Bisson, 2015). Non-trauma-focused treatments that target general avoidance coping strategies, such as acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 2012; Osaji, Ojimba, & Ahmed, 2020), may also be helpful in improving alcohol-related outcomes in veterans with PTSD, though further research is needed to evaluate this possibility. While these results represent an initial step in identifying factors important to recovery from traumatic events, continued study of the role of coping strategies in mediating PTSD and AUD is needed to inform and optimize treatment outcomes for these prevalent and disabling disorders.

Supplementary Material

Supplementary Material - Figures 1 & 2

Acknowledgements

The authors thank the veterans who participated in the National Health and Resilience in Veterans Study, and the Ipsos staff, particularly Robert Torongo, M.A. and Alyssa Marciniak, M.A., for coordinating data collection.

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.janxdis.2021.102496.

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