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Journal of Military, Veteran and Family Health logoLink to Journal of Military, Veteran and Family Health
. 2025 Nov 14;11(5):44–53. doi: 10.3138/jmvfh-2025-0010

PTSD symptom clusters and alcohol use among midlife women Veterans

Mary O Shapiro a, Mara L Ferrie b, Madison Crowder c, Dragana Lovre d, Amanda M Raines e
PMCID: PMC13293204  PMID: 42533989

Abstract

Introduction:

There are high rates of co-occurring posttraumatic stress disorder (PTSD) and alcohol use among women Veterans. Given the growing number of midlife women Veterans utilizing Veterans Health Administration (VHA) care and their unique stressors, the purpose of the current study was to examine the unique relationships between PTSD symptom clusters and alcohol use among this group of women.

Methods:

Fifty treatment-seeking midlife women Veterans (Mage = 50.00; 72% Black/African American) completed self-report measures on demographics, alcohol use and behaviours, and PTSD symptoms as part of their intake at a Veterans Affairs (VA) general mental health clinic.

Results:

Findings indicated that alcohol use was associated with PTSD symptom severity, as well as the intrusions, negative cognitions and mood, and arousal PTSD symptom clusters, but not the avoidance PTSD symptom cluster, after accounting for branch of service.

Discussion:

Findings of the current study are in line with previous research highlighting the unique relationship between alcohol use and PTSD symptoms. Our sample was primarily Black/African American midlife women, which may limit the generalizability of our findings. Given high rates of alcohol use and mental health symptoms among women at midlife, providers and researchers alike should aim to better understand the intersection of perimenopause/menopause and mental health outcomes to provide comprehensive health care for at-risk Veterans.

Key words: alcohol use, menopause, midlife, perimenopause, women Veterans

Lay Summary

Given the growing number of midlife women Veterans utilizing Veterans Health Administration care and their unique stressors at midlife, the purpose of the current study was to examine the unique relationships between posttraumatic stress disorder (PTSD) symptoms and alcohol use among midlife Veteran women. Our results showed that alcohol use was significantly associated with PTSD symptom severity, as well as the intrusions, negative cognitions and mood, and arousal PTSD symptom clusters, but not the avoidance PTSD symptom cluster. Given high rates of alcohol use and mental health symptoms among women at midlife, providers and researchers alike should aim to better understand the intersection of perimenopause/menopause and mental health sequelae to provide comprehensive health care for at-risk Veterans.

Introduction

Alcohol use is widespread in the general population. According to the World Health Organization, approximately two billion people worldwide consume alcohol, and an estimated 39.5% of those engage in hazardous alcohol use.1 Although the definition of hazardous or problematic alcohol use varies depending on several factors (e.g., culture, gender2), the link between greater alcohol use and mental health disorders is well documented.1 One of the most commonly co-occurring mental health concerns associated with alcohol use is posttraumatic stress disorder (PTSD). PTSD, which is characterized by a chronic stress reaction following exposure to a traumatic event,3 comprises 20 symptoms divided across four related yet distinct domains, including traumatic intrusions (e.g., nightmares, flashbacks), avoidance of internal and external reminders of the event (e.g., memories, people, situations), negative alterations in cognition and mood (e.g., inability to experience positive emotions, or persistent negative beliefs), and alterations in arousal and reactivity (e.g., difficulty sleeping, hypervigilance). PTSD affects approximately 6% of Americans in their lifetime,4 with comorbidity estimates for lifetime problematic alcohol use and PTSD at approximately 42%.5

Compared to either mental health condition alone, the co-occurrence of PTSD and hazardous alcohol use is associated with greater symptom severity6,7 and higher rates of relapse.8,9 Notably, PTSD and hazardous alcohol use are more prevalent among Veterans than among civilians. To illustrate, 15%-17% of Veterans who deployed to Iraq or Afghanistan met diagnostic criteria for PTSD,10-12 and co-occurring hazardous alcohol use among Veterans is experienced by up to 54%.13,14 Therefore, Veterans are a particularly vulnerable population for experiencing this co-occurrence.

Among Veterans, one group that is particularly important to consider when examining the co-occurrence of PTSD and alcohol use is women. As with their male counterparts, the co-occurrence of PTSD and alcohol use is exceedingly common among women Veterans. For example, previous work has found approximately 50% of women endorse PTSD and alcohol misuse,16,17 with women Veterans endorsing higher symptom severity than non-Veterans.18–20 The co-occurrence of PTSD and hazardous alcohol use is particularly concerning among midlife women Veterans given that this age group reports a high incidence of trauma history/PTSD and mental health symptoms,22,23 with midlife women Veterans having higher rates of substance misuse when compared to younger Veterans.16

In addition to the high rates of PTSD symptoms and alcohol use among midlife Veteran women, this group is a rapidly expanding cohort of Veterans Health Administration (VHA) care users15 and they have unique experiences and stressors. Specifically, women at midlife (i.e., age 40-60) are often entering or experiencing perimenopause or menopause, two reproductive stages wherein women often face many transitions and challenges. For example, women at this life stage are often managing role transitions (e.g., children and aging parents), physical signs of aging, hormone instability, and loss of fertility.24,25 Further, perimenopausal and menopausal women experience many physical health changes as well, such as higher rates of obesity, hypertension, and vasomotor symptoms (e.g., night sweats, hot flashes24,26). This transition to midlife also leads to an increased vulnerability to mental health problems. For example, during midlife, women experience increased anxiety symptoms and vasomotor symptoms (e.g., 80% of women experience hot flashes during menopause27), which may reinforce and intensify anxiety and PTSD symptoms during this time.28,29 Moreover, women Veterans seem to be more vulnerable to negative experiences during perimenopause and menopause, with research finding women Veterans endorse elevated rates of vasomotor symptoms and lower quality of life for health reasons when compared to non-Veterans.30

Given the high rates of co-occurring PTSD and problematic alcohol use among women Veterans, and the increased risk that the midlife transition presents, better understanding the relationship between specific PTSD symptoms (i.e., symptom clusters) and alcohol use is warranted to help guide treatment recommendations among this population. Several studies have documented the associations between the PTSD symptom clusters and hazardous alcohol use among diverse (i.e., mixed gender Veteran and civilian) samples and produced mixed findings.31–33 However, many of these investigations used prior conceptualizations of PTSD symptoms (e.g., Diagnostic and Statistical Manual of Mental Disorders, 4th ed.34). Looking to more recent work, Walton and Raines35 found the PTSD intrusions, arousal/reactivity, and negative alterations in cognitions and mood symptom clusters to be significantly associated with hazardous alcohol use among treatment seeking Veterans. Additional work by Guina and colleagues36 found all four Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5)3 PTSD symptoms clusters were significantly associated with alcohol use problems among individuals at an outpatient military medical centre. Although these investigations used an updated conceptualization of PTSD, they relied on samples that included civilians and/or consisted of mostly men.35,36 Despite being important, these findings may not extend to other groups, such as women at midlife, given the unique stressors and transitions that they experience.

Taken together, the extant literature has documented high rates of co-occurring PTSD and hazardous alcohol use among Veterans including women. Given the growing number of women Veterans utilizing VHA care,15 half of which are in midlife, and their unique experiences and stressors (e.g., hormone changes, role transitions24,25,27), the purpose of the current study was to conduct a preliminary examination into the unique relationships between PTSD symptom clusters and alcohol use among midlife treatment-seeking women Veterans. Based on previous research,35,36 we hypothesized that hazardous alcohol use would be associated with greater PTSD symptom severity. However, given the paucity of research examining the PTSD symptom clusters and hazardous alcohol use among this population, as well as the mixed results in the literature, we did not make specific predictions regarding the PTSD symptom clusters.

Methods

Participants and procedures

The sample consisted of 50 midlife women Veterans presenting for mental health care at a general mental health clinic at a southeastern Veterans Affairs (VA) hospital. As part of their mental health intake, Veterans completed a diagnostic interview and a brief set of self-report questionnaires to assist with diagnostic clarification and treatment planning. Notably, these data were collected as part of routine clinical care and, therefore, informed consent for research was not obtained. However, the VA Institutional Review Board approved the use of this de-identified data for research purposes, and a waiver of informed consent and HIPPA authorization was granted.

The current study aimed to examine the relationship between hazardous alcohol use and PTSD symptoms among midlife women Veterans. Therefore, analyses were restricted to women Veterans between the ages of 40 and 60 years old (Mage = 50.00, SD = 5.81) given that they were more likely to be experiencing perimenopause or menopause. The self-reported racial/ethnic breakdown was as follows: 72% Black/African American, 16% White/Caucasian, 2% Asian/Pacific Islander, 2% American Indian/Alaskan Native, and 8% other (e.g., biracial). In terms of marital status, most of the sample was divorced (36.0%), followed by married (28.0%), never married (26.0%), separated (6.0%), and widowed (4.0%). Regarding military service characteristics, women were dichotomized into two groups based on previous research that found elevated alcohol consumption among army and Marine Veterans compared to other service branches.35,37,38 Fifty-two percent of the sample served in the army or Marines, with the remaining 48% serving in another branch (e.g., navy, air force, national guard, and coast guard). Most of the sample served in Operation Desert Storm (ODS; 32.6%), followed by Operation Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND; 28.3%), other (e.g., peacekeeping missions; 2.2%), with 8.7% of the sample serving in multiple war zones, and 28.3% never having served in a war zone. All participants included in the study endorsed experiencing a Criterion A traumatic event according to the PTSD Checklist for DSM-5 (PCL-5).39 Regarding trauma exposure, the trauma type breakdown was as follows: sexual assault (18%), physical assault (18%), combat (14%), accident (8%), and witnessing someone else die (6%), with 36% endorsing other traumatic events across various categories (e.g., natural disaster, traumatic childbirth).

Measures

Demographic questionnaire. A self-report demographic questionnaire was used to collect basic demographic information including age, race, marital status, military branch of service, and war zone served. Consistent with prior research suggesting higher rates of alcohol use within the army and Marines,35,40 a dichotomized branch of service variable was created and included as a covariate (0 = navy, air force, national guard, or coast guard; 1 = army or Marines).

PCL-5 with Criterion A.39 The PCL-5 with Criterion A is a comprehensive assessment tool designed to evaluate exposure to potentially traumatic events and subsequent PTSD symptoms. Respondents were first asked to identify their worst traumatic event using a list of 17 items and then asked to indicate their level of exposure (e.g., “happened to me” and “witnessed it”). Following this, respondents were instructed to read a list of symptoms and indicate their level of distress as it related to each within the past month using a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely). The PCL-5 results in a total score, and sub-scales correspond to the DSM-5 PTSD symptom clusters (i.e., intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity). The PCL-5 is commonly used to index trauma exposure and subsequent symptoms in research and clinical settings and has demonstrated strong psychometric properties in prior research.41 In the current study, the PCL-5 total and sub-scale scores demonstrated adequate to excellent internal consistency (Cronbach α’s = 0.83-0.97).

Alcohol Use Disorder Identification Test (AUDIT).42 The AUDIT is a 10-item self-report questionnaire designed to assess hazardous alcohol use and identify potential alcohol use disorders in the past year. Veterans were asked to rate their alcohol consumption patterns on a scale from 0 (never) to 4 (daily or almost daily) and provide information about alcohol-related behaviours and consequences. This tool provides a total score that indicates the severity of hazardous alcohol use. The AUDIT is widely used in clinical and research settings and has demonstrated strong psychometric properties.42 Consistent with prior research, this scale demonstrated good internal consistency (Cronbach’s α = 0.87) in the present investigation.

Patient and public involvement

Given that data were collected among those presenting for mental health care at a VA hospital and collected as part of routine clinical care, neither patients nor members of the public were involved in this research.

Results

All analyses were conducted using IBM SPSS Statistics, version 29 (IBM Corp., Armonk, NY). First, means, standard deviations, and zero-order correlations between all variables of interest were examined (Table 1). The mean AUDIT total score did not meet the clinical cutoff (i.e., AUDIT total score > 8) for hazardous alcohol use43 but was similar to that found in research using treatment-seeking women Veterans.44 The mean PCL-5 total score was above the clinical cutoff score (i.e., PCL-5 total score > 3139) and consistent with clinical samples of women Veterans with PTSD.45,46 In terms of correlations, as expected, PCL-5 total and symptom cluster scores were positively and significantly associated with the AUDIT total score.

Table 1.

Zero-order correlation, means, and standard deviations

Measure 1 2 3 4 5 6 7 M SD
1. AUDIT Tot -- 4.16 5.36
2. PCL-5 Tot 0.44** -- 44.60 22.15
3. PCL-5 Int 0.39* 0.92*** -- 11.11 6.57
4. PCL-5 Av 0.23 0.84*** 0.73*** -- 4.54 2.50
5. PCL-5 Ncm 0.41* 0.95*** 0.79*** 0.80*** -- 15.26 8.17
6. PCL5 Ar 0.50** 0.95*** 0.86*** 0.71*** 0.85*** -- 13.10 6.64
7. Branch -0.12 0.31* 0.11 0.32* 0.33* 0.29* -- -- --
Open in a new tab

AUDIT Tot = Alcohol Use Disorder Identification Test, total score; PCL-5 Tot = PTSD Checklist for DSM-5, total score; PCL-5 Int = PTSD Checklist for DSM-5, intrusions sub-scale; PCL-5 Av = PTSD Checklist for DSM-5, avoidance sub-scale; PCL-5 Ncm = PTSD Checklist for DSM-5, negative alterations in cognition and mood sub-scale; PCL-5 Ar = PTSD Checklist for DSM-5, changes in arousal and reactivity sub-scale; Branch = branch of service.

*

p < 0.05.

**

p < 0.01.

***

p < 0.001.

Next, a series of linear regression models were performed to examine the associations between PTSD symptoms (as measured by the PCL-5 total and symptom cluster scores) and hazardous alcohol use (as measured by the AUDIT total score). All preliminary analyses indicated no violations or threats of multicollinearity, homoscedasticity, or normality. In each model, AUDIT total scores were entered as the dependent variable and PCL-5 total and symptom cluster scores (i.e., intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity) were entered as the independent variables. Consistent with prior research,35 branch of service was included as a covariate. Please see Table 2 for model details. Results indicated that PCL-5 total scores were significantly associated with greater hazardous alcohol use after covarying for branch of service. Further, the PCL-5 intrusions, negative cognitions and mood, and arousal symptom clusters were significantly associated with greater hazardous alcohol use after covarying for branch of service. Finally, the PCL-5 avoidance symptom cluster was not significantly associated with greater hazardous alcohol use after accounting for branch of service.

Table 2.

Regression analyses for PTSD severity and symptoms predicting alcohol use

β t sr 2
AUDIT Total
Branch -0.18 -1.12 0.03
PCL-5 Tot 0.48** 3.05 0.22
AUDIT Total
Branch -0.09 -0.56 0.01
PCL-5 Int 0.39* 2.45 0.15
AUDIT Total
Branch -0.13 -0.79 0.02
PCL-5 Av 0.25 1.50 0.06
AUDIT Total
Branch -0.20 -1.26 0.04
PCL-5 Ncm 0.47** 2.91 0.20
AUDIT Total
Branch -0.19 -1.27 0.03
PCL-5 Ar 0.53** 3.58 0.27
Open in a new tab

AUDIT Total = Alcohol Use Disorder Identification Test, total score; Branch = branch of service; PCL-5 Tot = PTSD Checklist for DSM-5, total score; PCL-5 Int = PTSD Checklist for DSM-5, intrusions sub-scale; PCL-5 Av = PTSD Checklist for DSM-5, avoidance sub-scale; PCL-5 Ncm = PTSD Checklist for DSM-5, negative alterations in cognition and mood sub-scale; PCL-5 Ar = PTSD Checklist for DSM-5, changes in arousal and reactivity sub-scale.

*

p < 0.05.

**

p < 0.01.

Discussion

The purpose of the current study was to examine the unique relationships between the PTSD symptom clusters and alcohol use among midlife treatment-seeking women Veterans. Results indicated that greater alcohol use was significantly associated with greater PTSD symptom severity, as well as the intrusions, negative cognitions and mood, and arousal PTSD symptom clusters. However, we did not find a significant association between alcohol use and the avoidance PTSD symptom cluster. These results are novel and important given that they are a first look at the relationship between elevated alcohol use and PTSD symptoms among a group of women Veterans encountering unique transitions and challenges.

Our finding that elevated alcohol use was significantly positively associated with the intrusions, negative cognitions and mood, and arousal PTSD symptom clusters, but not the avoidance PTSD symptom cluster, is consistent with previous research35 using Veteran (men and women) samples and the updated DSM-53 conceptualization of PTSD. Our findings, in combination with prior work,35,36 support the self-medication hypothesis, which proposes that individuals with distressing symptoms (e.g., nightmares, hypervigilance, low mood) may use alcohol to reduce distress and/or increase positive affect.47 As previously noted, we did not find a significant relationship between the PTSD avoidance symptom cluster and alcohol use. Although we did not test the causal pathways in the current analyses, this finding in combination with other research35 suggests that alcohol may not work to increase avoidance but rather decreases avoidance by temporarily reducing the distress associated with confronting anxiety-provoking trauma-related reminders.

Our findings are also in line with recent work highlighting high rates of hazardous alcohol use and mental health symptoms among midlife women Veterans.16,22,23 Specifically, the extant literature has documented high rates of co-occurring PTSD symptoms and hazardous alcohol use among women Veterans. Further, midlife women Veterans are an increasingly expanding group of VHA care users,15 and they have unique stressors, including role transitions (e.g., aging parents and children), physical signs of aging, loss of fertility,24,25 myriad physical health changes (e.g., higher rates of obesity, hypertension, and vasomotor symptoms24,26), and increased vulnerability to mental health difficulties (e.g., anxiety, PTSD symptoms, depression28,29,48–50). Additionally, our study population comprised mostly Black/African American women who may be particularly affected by the duration of vasomotor symptoms. In a study evaluating the duration of vasomotor symptoms over the menopause transition, Black/African American women (compared with women of other racial/ethnic groups) reported the longest total vasomotor symptoms duration (median = 10.151). In addition to vasomotor symptoms, insomnia (a symptom of PTSD) is an additional stressor during perimenopause and menopause, which may serve to intensify mental health symptoms. For example, a recent meta-analysis showed that the overall prevalence of sleep disorders among postmenopausal women was 51.6%.52

There are several implications of the current study. First, empirically supported treatments exist for the co-occurrence of PTSD symptoms and elevated alcohol use (e.g., Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure [COPE]53). However, no research to date has examined the utility of these treatments among midlife women Veterans. Given the unique stressors and concerns of this population, future work should apply treatments, such as COPE, to understand whether their effectiveness is generalizable. Further, given the negative feedback cycle between alcohol use, mental health symptoms (e.g., stress, low mood), and perimenopause/menopause symptoms, providers (e.g., psychologists, psychiatrists, general practitioners) working with midlife women should make sure to comprehensively (i.e., physical and mental health symptoms as appropriate) assess these symptoms given their impact on midlife women and the availability of treatments to address symptoms at midlife (e.g., cognitive behavioural therapy [CBT], hormone replacement therapy [HRT]). Additionally, among premenopausal women, greater alcohol use is positively and consistently associated with increased risk of both prevalent and incident early-onset vasomotor symptoms.54 Therefore, reducing alcohol use may help prevent and/or reduce bothersome vasomotor symptoms in premenopausal women. In fact, empirically supported treatments exist for symptoms of perimenopause and menopause, including HRT55 and CBT for menopause (CBT-Meno56). Assessing for perimenopause/menopause symptoms and incorporating these treatments as needed is important to provide comprehensive health care for midlife women and may help alleviate symptoms and reduce the impact of this reproductive transition. Given the many role transitions that midlife women encounter, asking women about these difficulties and addressing their concerns through empirically supported treatments like interpersonal psychotherapy57 is crucial. Finally, future research aimed at understanding the optimal timing when treating alcohol use and PTSD symptoms within the context of reproductive health concerns, as well as the impact of transdiagnostic treatments such as acceptance and commitment therapy, is needed.

Despite these clinical implications, the current study had several limitations. First, we used a small sample size, and all variables of interest were cross-sectional and measured through self-report. Future work should attempt to replicate these findings using larger samples while using longitudinal and multi-method approaches to better understand the causal relationships among these constructs. Second, our sample comprised treatment-seeking midlife women Veterans, which may limit the generalizability of our findings to non-treatment-seeking populations, as well as to women outside the midlife age range. Notably, while our focus was a clinically elevated sample, we did not formally diagnose PTSD or substance use disorders, and mean AUDIT scores in the current study were below the clinical cut-off for alcohol use disorders.43 Further, our study used age as a proxy indicative of the perimenopause/menopause phase, and we did not directly assess the presence or absence of perimenopause/menopause symptoms. Future work on PTSD and alcohol use while integrating more comprehensive information about diagnostic status and perimenopause/menopause symptoms is crucial to better understand the clinical implications of these findings. Last, our sample primarily self-reported as Black/African American women. Accordingly, our findings may not be applicable to other racial/ethnic groups. Further, future research should explore how structural and sociocultural factors, such as systemic racism, stigma, and disparate access to comprehensive care, may intricately influence the manifestation and trajectory of PTSD symptoms and patterns of alcohol use among women Veterans.

In summary, our study addressed an important gap in the literature by examining the relationship between PTSD symptoms and elevated alcohol use among an at-risk group of women Veterans. Consistent with prior research,35 we found that greater alcohol use was significantly associated with the intrusions, negative cognitions and mood, and arousal PTSD symptom clusters, but not with the avoidance PTSD symptom cluster. Given that the number of women Veterans is growing exponentially, and midlife women are faced with myriad unique physical and mental health challenges, understanding factors that may impact mental health among this group is important. Future work aimed at replicating and extending our findings through causal and intervention-focused research is crucial to enhance the generalizability and impact of this work.

Acknowledgments

Competing Interests

The authors have nothing to disclose.

Ethics Approval

This study was approved by the Southeast Louisiana Veterans Health Care System Institutional Review Board, New Orleans, Louisiana, United States, on March 2, 2018.

Informed Consent

N/A

Registry and Registration No. of the Study/Trial

N/A

Animal Studies

N/A

Peer Review

This article has been peer reviewed.

Biographies

Mary O. Shapiro is a clinical investigator and psychologist at the Southeast Louisiana Veterans Health Care System. Her research focuses on the intersection of trauma and reproductive health.

Mara L. Ferrie is a clinical investigator and psychologist at the Southeast Louisiana Veterans Health Care System. Her research focuses on the intersection of trauma and substance use.

Madison Crowder is a postdoctoral resident at the Veteran Affairs Eastern Colorado Health Care System. Her clinical interests focus on the intersection of mental and physical health conditions.

Dragana Lovre is a clinical investigator and an endocrinologist at the Southeast Louisiana Veterans Health Care System. Her research focuses on women’s health and the impact of sex hormones.

Amanda M. Raines is a clinical investigator and psychologist at the Southeast Louisiana Veterans Health Care System. Her research focuses on the intersection of trauma, suicidal ideation, and substance use among Veterans.

Funding Statement

This study is the result of work supported with resources and the use of facilities at the Southeast Louisiana Veterans Health Care System in New Orleans, Louisiana. Mary O. Shapiro is supported by the United States Department of Veterans Affairs (Health Systems Research Service) under Career Development Award-2 IK2HX003681-01A2. Amanda M. Raines is supported by the United States Department of Veterans Affairs (Clinical Science Research and Development Service [CSRD]) under Career Development Award-2 (CDA-2) IK2CX001978-02. Dragana Lovre is supported by the United States Department of Veterans Affairs CSRD CDA-2 IK2CX002225-02. The funding source had no other role other than financial support.

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