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. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: Addict Behav. 2019 Oct 24;102:106181. doi: 10.1016/j.addbeh.2019.106181

The Influence of Posttraumatic Stress Disorder and Recurrent Major Depression on Risk-Taking Propensity following Trauma Script Exposure among Patients with Substance Use Disorders

Ariana G Vidaña 1, Courtney N Forbes 1, Kim L Gratz 1, Matthew T Tull 1,*
PMCID: PMC6936599  NIHMSID: NIHMS1545094  PMID: 31775063

Abstract

Although evidence suggests that risk-taking among individuals with co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) may be precipitated by trauma-related emotional distress, studies have yet to examine moderators of this effect. One moderator worth investigating is recurrent major depressive disorder (MDD), given its influence on emotional responding and subsequent behavior. This study examined the moderating role of recurrent MDD in the relation of PTSD to risk-taking propensity following neutral and trauma scripts among SUD patients. Participants were 193 patients with and without current PTSD and/or recurrent MDD in residential SUD treatment. Risk-taking propensity, as assessed through the Balloon Analogue Risk Task (BART), was evaluated following a neutral script and a personalized trauma script. A significant script by PTSD by recurrent MDD interaction was found. Participants with PTSD and recurrent MDD exhibited significantly lower risk-taking following the trauma script relative to participants with PTSD but no recurrent MDD. Moreover, participants with PTSD and recurrent MDD exhibited a significantly smaller increase in risk-taking following the trauma script (relative to the neutral script) than participants with PTSD but no recurrent MDD. Participants with PTSD and recurrent MDD did not differ significantly from participants without PTSD. Results provide support for the context-dependent nature of risk-taking among PTSD-SUD patients without (vs. with) recurrent MDD. Results also highlight the importance of considering the presence of recurrent MDD in research and/or clinical work with SUD patients with PTSD.

Keywords: Depressive Disorders, Impulsivity, PTSD, Substance Abuse, Trauma

1. Introduction

Among individuals seeking treatment for a substance use disorder (SUD), approximately 26–60% meet criteria for lifetime posttraumatic stress disorder (PTSD; Vujanovic & Back, 2019), compared to the PTSD prevalence rate of 8.3% in the general population (Kilpatrick et al., 2013). The co-occurrence of PTSD with a SUD is associated with a more severe and chronic clinical course than a SUD alone (Back et al., 2000; McCauley, Killeen, Gros, Brady, & Back, 2012; Najavits et al., 2007; Ouimette, Coolhart, Funderburk, Wade, & Brown, 2007), and a growing body of literature has shown that the co-occurrence of PTSD and SUDs is associated with elevated rates of risk-taking behaviors (Gratz & Tull, 2010; Weiss, Tull, Borne, & Gratz, 2013; Weiss, Tull, Sullivan, Dixon-Gordon, & Gratz, 2015); that is, behaviors that are typically associated with rewarding consequences in the short-term but also have the potential for harm (Leigh, 1999; Lejuez et al., 2002).

Emerging evidence suggests that the risky behaviors observed among individuals with co-occurring PTSD-SUD may be precipitated by trauma-related emotional distress. For example, among SUD patients, PTSD is associated with an attentional bias for drug cues (Tull, McDermott, Gratz, Coffey, & Lejuez, 2011) and greater substance cravings (Saladin et al., 2003; Tull, Kiel, McDermott, & Gratz, 2013) following trauma cue exposure. These results have generally been explained through the lens of an affective processing model of negative reinforcement (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004). According to this model, given that the co-occurrence of PTSD and SUDs is associated with elevated levels of emotion dysregulation (McDermott, Tull, Gratz, Daughters, & Lejuez, 2009), individuals with PTSD-SUD may find it difficult to tolerate the intense emotional arousal stemming from exposure to a trauma-related reminder. Consequently, they may be motivated to engage in behaviors that can bring about a rapid reduction in distress, such as aggressive behaviors, substance use, or risky sexual behavior.

Contrary to this explanation, however, a recent study found that SUD patients with PTSD exhibited lower risky decision making following a trauma script than a neutral script, as well as lower risky decision making following the trauma script than SUD patients without PTSD (Tull, Forbes, Weiss, & Gratz, 2019). These discrepant findings speak to the need to examine moderators of the relation of PTSD-SUD to risk-taking following trauma cue exposure. Specifically, a limitation of the extant literature on risk-taking among individuals with PTSD and SUDs is the failure to consider other disorders that may co-occur with PTSD and SUDs and influence risk-taking and/or emotional responding (i.e., the ways in which emotions are activated or experienced in response to specific cues). One disorder common among individuals with SUDs that also co-occurs with PTSD at a high frequency and warrants consideration as a moderator of the relation between PTSD and risk-taking is major depressive disorder (MDD; Kessler, Chiu, Demler, & Walters, 2005). For example, Cougle, Feldner, Keough, Hawkins, and Fitch (2010) found that 40% of individuals with current PTSD also met criteria for MDD. Likewise, elevated rates of MDD are observed among individuals with SUDs (15.15% current prevalence) compared to the general population (6.35% current prevalence; Grant et al., 2004), and even higher rates of MDD are observed within treatment-seeking SUD samples (e.g., 20.5%; Tull & Gratz, 2013). The co-occurrence of PTSD and MDD is typically associated with worse clinical outcomes, including greater distress and functional impairment, than the presence of either disorder alone (Kessler et al., 2005; Momartin, Silove, Manicavasagar, & Steel, 2004). Furthermore, MDD is associated with unique alterations in emotional responding that could influence risk-taking behavior.

Theory and research highlighting deficits in emotional responding, motivation, and behavior in MDD suggests that the presence of co-occurring MDD would be associated with decreased risk-taking behavior in the context of trauma-related distress and PTSD. For example, the emotion context insensitivity model of emotional responding suggests that MDD is characterized by decreased emotional responding to both positively and negatively-valenced stimuli (Bylsma, Morris, & Rottenberg, 2008; Rottenberg, Gross, & Gotlib, 2005). Given evidence that risk-taking behaviors may serve an emotion regulatory function (Tull, Weiss, Adams, & Gratz, 2012; Weiss, Tull, & Gratz, 2014), attenuated responding to negative stimuli may decrease risk-taking propensity among individuals with PTSD following exposure to a trauma-related reminder. Likewise, decreases in motivation and behavioral activation seen in MDD (including deficits in reward-seeking behavior; Ferster, 1973; Jacobson, Martel, & Dimidjian, 2001) could also attenuate risk-taking among PTSD-SUD patients with MDD, decreasing responsiveness to the potentially reinforcing consequences of risk-taking behavior.

This study sought to examine the moderating role of recurrent MDD in the relation of PTSD to risk-taking propensity following both neutral and trauma scripts among SUD patients. We chose to examine recurrent versus single episode MDD given (1) the high frequency with which recurrent MDD occurs (i.e., 50–75% of individuals with MDD have experienced more than one depressive episode; McClintock, Husain, Greer, & Cullum, 2010), and (2) that recurrent, relative to single episode, MDD is associated with greater emotional and cognitive dysfunction that could influence emotional responding and risk-taking (Elinson, Houck, Marcus, & Pincus, 2004; Paradis, Reinherz, Giaconia, & Fitzmaurice, 2006; Stordal et al., 2004; Vuorilehto, Melartin, & Isometsӓ, 2005). We hypothesized a significant 3-way interaction between PTSD (present vs. absent), recurrent MDD (present vs. absent) and script type (trauma vs. neutral) on risk-taking propensity. Specifically, we hypothesized that participants with PTSD but without recurrent MDD would exhibit the highest levels of risk-taking following trauma script exposure, as well as the greatest increase in risk-taking following the trauma script (relative to the neutral script). Conversely, the presence of recurrent MDD among participants with PTSD was expected to attenuate risk-taking following the trauma script, as well as limit differences in risk-taking following the neutral versus trauma scripts.

2. Method and Materials

2.1. Participants and Procedure

Participants were drawn from a sample of 226 participants in a residential SUD treatment facility. Participants that did not have complete data for the laboratory task (either due to not completing that portion of the study or errors in administration) or diagnostic interviews were excluded from the study. The final sample included 193 participants (92 women) with complete data reporting exposure to a PTSD Criterion A traumatic event on the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990). Participants ranged from 18 to 60 years of age (mean age = 34, SD = 10.11) and 60.6% identified as White, 36.3% as African-American, 1.6% as Latinx, 1.0% as Native-American, and 0.5% as Asian-American. Most had a high school education or less (62.6%) and an annual income of less than $20,000 (66.8%). Approximately 42% of participants were court-ordered to treatment, and 71.6% had previously received some form of outpatient or inpatient SUD treatment. See Table 1 for diagnostic data.

Table 1.

Diagnostic data across all participants.

Disorder % Present (n)
Posttraumatic Stress Disorder 25.9% (50)
Major Depressive Disorder, Recurrent 54.5% (105)
Major Depressive Disorder 25.9% (50)
Panic Disorder with/without Agoraphobia 26.4% (51)
Social Anxiety Disorder 24.9% (48)
Obsessive-Compulsive Disorder 11.9% (23)
Generalized Anxiety Disorder 31.6% (61)
Alcohol Dependence 64.8% (125)
Cocaine Dependence 59.6% (115)
Opioid Dependence 24.9% (48)
Marijuana Dependence 30.1% (58)
Sedative Dependence 20.7% (40)
Stimulant Dependence 21.2% (41)
Hallucinogen Dependence 3.1% (6)
Polysubstance Use Disorder 9.3% (18)
Antisocial Personality Disorder 41.5% (80)
Borderline Personality Disorder 35.2% (68)
Number of Anxiety Disorders
  No Anxiety Disorders 46.6% (90)
  1 Anxiety Disorder 25.4% (49)
  2 Anxiety Disorders 17.6% (34)
  3+ Anxiety Disorders 10.4% (20)
Number of Substance Use Disorders
  1 Substance Use Disorder 35.2% (69)
  2 Substance Use Disorders 30.1% (58)
  3 Substance Use Disorders 15.0% (29)
  4+ Substance Use Disorders 19.7% (38)
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Note. All diagnoses are current.

Standard treatment at this facility involves a combination of strategies from Alcoholics Anonymous and Narcotics Anonymous, as well as groups focused on relapse prevention. The facility requires complete abstinence from drugs and alcohol with the exception of caffeine. Aside from scheduled activities, residents are not permitted to leave the treatment facility. Contract duration is approximately 30 days for all patients.

All procedures were reviewed and approved by relevant Institutional Review Boards. Data were collected as part of a larger study examining differences in emotional responding and risk-taking as a function of PTSD, alcohol dependence, and cocaine dependence. As a result, only patients with alcohol and/or cocaine dependence were recruited (although participants could also be dependent on other substances). Other inclusion criteria included: 1) having a Mini-Mental Status Exam (Folstein, Folstein, & McHugh, 1975) score of ≥ 24 (no significant cognitive impairment) and 2) absence of a current psychotic disorder. Eligible participants were recruited for this study no sooner than 72 hours after treatment entry to limit interference of withdrawal symptoms on study engagement. Those meeting inclusion criteria were provided with information about study, following which written informed consent was obtained.

This study involved three sessions conducted on separate days. During the initial assessment session, participants were administered diagnostic interviews and a series of questionnaires. After this session, participants scheduled a second and third session and were compensated with $25. The procedures for the second and third sessions were the same except for the script presented. Script presentation was counterbalanced, and the order of script presentation was equally balanced across participants with and without PTSD. During each experimental session, participants first rated their current negative affect. They then listened to the one-minute tape. After the tape was completed, participants were instructed to close their eyes and imagine vividly the event taking place in real-time for one minute. Participants then provided another rating of their current negative affect. Participants were then administered the BART. All participants received standard instructions on how to complete the BART. After the BART, the next experimental session was scheduled. Participants were compensated with $15 for each experimental session, regardless of their performance on the BART.

To ensure that participants did not leave the experimental sessions in an elevated state of distress, several precautions were taken. First, participants provided a rating of their emotional distress and substance cravings at the start and end of each experimental session. If ratings of distress and/or cravings increased by more than 2 points from the start to the end of the experimental session, participants were taken through a series of empirically-supported skills for managing emotional distress and cravings. Following skill use, participants were again asked to rate their distress and cravings. This procedure was repeated until the participant’s distress and cravings were within 2 points of their baseline levels. This procedure was required for 17 participants (8.8%); in all cases, distress and cravings returned to baseline levels after skill use.

2.2. Measures

2.2.1. Diagnostic assessment measures

To determine the presence of Criterion A traumatic exposure and current PTSD, all participants were interviewed using the CAPS for the DSM-IV (Blake et al., 1990. The psychometric properties of the CAPS have been supported in a variety of different populations, including SUD patients (e.g., Blake et al., 1990; Brown, Stout, & Mueller, 1996; Shalev, Freedman, Peri, Brandes, & Sahar, 1997; Weathers, Keane, & Davidson, 2001). Participants were also administered the Mini International Neuropsychiatric Interview, Version 6.0 (MINI; Sheehan et al., 2009) to assess for current DSM-IV Axis I disorders (with the exception of PTSD and SUDs) and antisocial personality disorder. The MINI was used to assess for recurrent and single (current or past) episode MDD. The Structured Clinical Interview for the DSM-IV (First, Gibbon, Spitzer, & Williams, 1996) was used to assess for current SUDs. Finally, borderline personality disorder was assessed using the Diagnostic Interview for DSM-IV Personality Disorders (Zanarini, Frankenburg, Sickel, & Yong, 1996).

Interviews were conducted by bachelors- or masters-level clinical assessors trained to reliability with the principal investigator (MTT) and co-investigator (KLG). Detailed information provided by each participant was collected by interviewers, and all data were reviewed by the principal investigator. In the case of ambiguous responses or disagreements, data were reviewed and discussed by the principal investigator and interviewer until a consensus was reached.

2.2.2. Scripts

Participants were asked questions about their most traumatic life event. Specifically, participants were asked to describe their traumatic event in detail. Throughout the recount, research personnel asked questions to obtain additional details regarding people, places, or situations associated with the traumatic event, as well as the thoughts, emotions, and bodily sensations experienced by the participant during the traumatic event. Participants’ responses were tape recorded, allowing research personnel to create a trauma script using the participant’s own language (see Keane et al., 1998; Lang & Cuthbert, 1984; Pitman, Orr, Forgue, de Jong, & Claiborn, 1987; Tull et al., 2011). A script approximately one minute in length describing the event was then created and recorded onto an audiotape. There is evidence that this procedure reliably induces emotional responses in PTSD samples (Lang, Levin, Miller, & Kozak, 1983; Orr, Pitman, Lasko, & Herz, 1993; Pitman et al., 1987), including SUD patients with PTSD (Tull et al., 2011). A standardized neutral script was also developed. The neutral script provided a description of generic activities involved in getting up in the morning. The neutral script was approximately one minute in length.

2.2.3. Measurement of script emotional reactivity

Participants were administered the negative affect subscale of the Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988) immediately prior to and following presentation of the trauma and neutral scripts to evaluate emotional reactivity to the scripts. Participants were asked to rate the extent to which they were currently experiencing 10 forms of negative affect on a scale from 1 (very slightly or not at all) to 5 (extremely). Overall negative affect was calculated by summing all items. Internal consistencies across all negative affect assessments (αs ≥ .85) were acceptable.

2.2.4. Measurement of risk-taking propensity

The Balloon Analogue Risk Task (BART; Lejuez et al., 2002) was used to assess risk-taking propensity. The BART has been used to assess risk-taking propensity in both nonclinical samples (Hunt, Hopko, Bare, Lejuez, & Robinson, 2005; Lejuez et al., 2002) and individuals with SUDs (Aklin, Tull, Kahler, & Lejuez, 2009; Bornovalova, Daughters, Hernandez, Richards, & Lejuez, 2005; Hopko et al., 2006; Tull et al., 2009). It is also associated with real-world risk-taking behaviors (Bornovalova, Gwadz, Kalre, Aklin, & Lejuez, 2008; Lejuez et al., 2002).

In administering the BART, participants are seated in front of a computer screen displaying a small simulated balloon accompanied by a pump button, a reset button, a permanent money earned display, a display indicating the amount of money earned on the current balloon, and a display indicating the number of pumps made on the current balloon. Participants are instructed to pump the balloon to earn as much money as possible, taking into consideration that the balloon could pop at any time. All balloons have the same probability of exploding. For each pump where the balloon does not explode, 2 cents are deposited in a temporary bank. If a balloon is pumped past its explosion point, the balloon explodes and all money in the temporary bank is lost. The next uninflated balloon then appears on the screen. At any point during each trial, the participant can stop pumping the balloon and click the reset button which transfers all money from the temporary bank to a permanent bank. After each balloon explodes or money is collected, a new balloon appears. There are 20 balloon trials.

The average number of pumps on balloons that do not explode (adjusted average number of pumps) is used as an index of risk-taking propensity. Higher scores indicate greater risk-taking propensity. This value is recommended as it is not constrained by the explosion points across balloons (Lejuez et al., 2002).

3. Results

Effect sizes (Cohen’s d and Cohen’s f), are reported for all findings. Suggested benchmarks for Cohen’s d are .20 (small effect), .50 (medium effect), and .80 (large effect; Cohen, 1988). Suggested benchmarks for Cohen’s f are .10 (small effect), .25 (medium effect), and .40 (large effect; Cohen, 1988).

3.1. Counterbalancing

To evaluate if counterbalancing was effective, a 2 (neutral script vs. trauma script) × 2 (neutral script presented first vs. trauma script presented first) repeated measures analysis of variance (ANOVA) was conducted with the adjusted average number of pumps on the BART following the neutral and trauma scripts serving as the dependent variables. No significant interaction was found, F (1, 191) = 2.60, p = .108, f = .078, indicating that risk-taking propensity following the neutral and trauma scripts was not affected by the order of script presentation.

3.2. Script emotional reactivity

To ensure that the trauma script resulted in an increase in negative affect and the neutral script did not, a series of 2 (current PTSD vs. no current PTSD) × 2 (recurrent MDD vs. no recurrent MDD) × 2 (pre-vs. post-script) repeated measures ANOVAs were conducted to evaluate change in negative affect from before to after the trauma and neutral scripts. All participants reported a significant increase in negative affect from pre-to post-trauma script, F (1, 189) = 141.19, p < .001, f = .859; however, this finding was qualified by a significant PTSD by time interaction, F (1, 189) = 7.27, p = .008, f = .181. Specifically, whereas participants with both current PTSD, t (49) = −8.18, p < .001, d = −1.25, and without PTSD, t (142) = −9.47, p < .001, d = −.84, reported a significant increase in negative affect from pre-to post-trauma script, this change was greater for those with PTSD, t (191) = −3.23, p = .001, d = −.52. No other main effects or interactions were significant for trauma script negative affect, Fs (1, 189) < 1.20, ps > .274, fs < .032. All participants reported a significant decrease in negative affect from pre-to post-neutral script, F (1, 189) = 5.55, p = .020, f = .154. No other main effects or interactions were significant for neutral script negative affect, Fs (1, 189) < 1.97, ps > .162, fs < .071.

3.3. Primary analyses

See Table 2 for descriptive data for the BART across diagnostic groups and script types. Acceptable skew and kurtosis were observed for the post-neutral script (skew = .59, kurtosis = −.07) and post-trauma script (skew = .90, kurtosis = 1.14) BART variables. To evaluate hypotheses, a 2 (neutral vs. trauma script) × 2 (current PTSD vs. no current PTSD) × 2 (recurrent MDD vs. no recurrent MDD) repeated measures ANOVA was conducted. Given that there was an unequal number of participants across groups, a Type III sums of squares analysis was utilized (Maxwell & Delaney, 2003). The adjusted average number of pumps on the BART following the neutral and trauma scripts served as the dependent variables. Significant interactions were explored with planned comparisons (one-tailed) where participants in the PTSD-MDD group would be compared to all other groups on risk-taking propensity following the trauma script, as well as change in risk-taking from the neutral script to the trauma script.

Table 2.

Descriptive statistics for the BART across groups and scripts.

Group Neutral Scripta Trauma Scripta
No PTSD and No Recurrent MDD (n = 69) 28.58 (17.82) 28.41 (18.68)
No PTSD and Recurrent MDD (n = 74) 23.58 (14.94) 24.85 (15.10)
PTSD and No Recurrent MDD (n = 19) 33.49 (15.42) 40.87 (20.81)
PTSD and Recurrent MDD (n = 31) 34.11 (17.80) 30.20 (17.65)
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Note. PTSD = posttraumatic stress disorder. MDD = major depressive disorder.

a

Numbers presented are the adjusted average number of pumps (means with standard deviations presented in parentheses).

Box’s M and Levene’s test were non-significant (ps > .056), indicating homogeneity of covariance and error variance, respectively, of the dependent variables across groups. Results demonstrated a significant script by recurrent MDD interaction, F (1, 189) = 5.21, p = .024, f = .149; however, this interaction was qualified by a significant script by PTSD by recurrent MDD interaction, F (1, 189) = 8.69, p = .004, f = .201 (see Table 3 and Figure 1). Planned comparisons revealed that participants with PTSD and recurrent MDD exhibited significantly lower risk-taking on the BART (i.e., lower average number of pumps on trials where balloons do not explode) following the trauma script relative to participants with PTSD and no recurrent MDD, t (48) = −1.94, p = .030, d = .55); they did not differ significantly from participants without PTSD (with or without recurrent MDD; ps > .05, ds < .33). Moreover, participants with PTSD and recurrent MDD exhibited significantly less of an increase in risk-taking following the trauma script (relative to the neutral script) than participants with PTSD and no recurrent MDD, t (48) = −2.93, p = .003, d = .81; they did not differ significantly from participants without PTSD (with or without recurrent MDD) in change in risk-taking propensity from the neutral script to the trauma script (ps > .10, ds < .24).

Table 3.

Output for 2 (neutral vs. trauma script) × 2 (current PTSD vs. no PTSD) × 2 (recurrent MDD vs. no recurrent MDD) repeated measures ANOVA

Effect df Mean Square F p Cohen’s f
Script 1 92.52 1.12 .291 .025
Script × PTSD 1 24.77 0.30 .584 .000
Script × Recurrent MDD 1 429.68 5.21 .024 .149
Script × Recurrent MDD × PTSD 1 716.72 8.69 .004 .201
Error 189 82.45
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Note. PTSD = posttraumatic stress disorder. MDD = major depressive disorder.

Figure 1.

Figure 1.

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Script × PTSD × Recurrent MDD Interaction

The primary analysis was repeated with the inclusion of covariates that have been previously been found to be positively or negatively associated with risk-taking, including age (Lejuez et al., 2002), gender (Lejuez et al., 2002), borderline personality disorder (Darke, Williamson, Ross, Teesson, & Lynskey, 2004), antisocial personality disorder (Kelley & Petry, 2000), number of anxiety disorders (Maner et al., 2007), and number of SUDs that participants currently met criteria for (Kaye et al., 2014; Lejuez et al., 2002). Further, psychotropic medication use was also included as a covariate, given that some psychotropic medications could influence risk-taking propensity. The inclusion of these variables as covariates ensures that the observed differences in risk-taking between PTSD-SUD participants with versus without recurrent MDD were not due to the presence of other forms of psychopathology, demographics, or psychotropic medication use. The significant script by PTSD by recurrent MDD interaction remained, F (1, 182) = 9.43, p =.002, f = .214, as did the pattern of findings associated with the interaction.

Finally, given our proposition that single episode MDD would be less likely than recurrent MDD to influence risk-taking among SUD patients with PTSD following trauma script exposure, we reran our primary analysis replacing recurrent MDD with the presence of single episode MDD as an independent variable. Participants with recurrent MDD were removed from analyses. No significant main effects or interactions were found (Fs [1, 84] < 2.56, fs < .135), providing support for the specific relevance of recurrent MDD.1

4. Conclusion

Consistent with hypotheses, participants with PTSD and recurrent MDD exhibited significantly lower levels of risk-taking following trauma script exposure, as well as less of a change in risk-taking following the trauma script (relative to the neutral script), compared to participants with PTSD but no recurrent MDD. Notably, participants with PTSD and recurrent MDD exhibited levels of risk-taking following the trauma script that were not significantly different from those observed among participants without PTSD (with or without recurrent MDD). Results provide support for the context-dependent nature of risk-taking among SUD patients with PTSD (and no recurrent MDD), consistent with previous studies (Saladin et al., 2003; Tull et al., 2011, 2013). Moreover, findings highlight the relevance of risk-taking propensity as a specific negative consequence, correlate, or symptom of PTSD, supporting its consideration as a subtype of PTSD and its inclusion in current diagnostic conceptualizations of PTSD (Contractor & Weiss, 2019). Although our data do not speak to the specific function of the risk-taking observed following trauma script exposure among PTSD-SUD patients without recurrent MDD, findings of significantly greater risk-taking following the trauma script (relative to the neutral script) among this group, as well as past evidence that risky behaviors serve an emotion regulatory function (both in general and among SUD patients with PTSD in particular; Tull et al., 2012; Weiss, Tull, Viana, Anestis, & Gratz, 2012), suggest that this risk-taking behavior may have served an emotion regulatory function. To further elucidate the emotion regulatory function of risk-taking, future research in this area would benefit from assessing specific motives for risk-taking behaviors (e.g., negative affect reduction, positive affect elevation, self-punishment), as well as examining the short- and long-term emotional consequences of engaging in such behaviors.

Findings also highlight the importance of considering moderators of the relation between PTSD-SUD and risk-taking following exposure to a trauma-related cue. Although the presence (vs. absence) of PTSD was associated with higher levels of negative affect in response to the trauma script, only PTSD participants without recurrent MDD exhibited greater risk-taking following the trauma script (relative to the neutral script). Conversely, given that recurrent MDD status was not found to influence negative affect reactivity to the trauma script, these differences in risk-taking following the trauma script may have been driven by decreases in behavioral outputs and/or responsivity to reward associated with recurrent MDD. For example, individuals with clinical levels of depression symptoms have been found to exhibit greater risk aversion than non-depressed controls (Smoski et al., 2008), consistent with evidence that MDD is associated with decreases in approach-oriented behavior (Jacobson et al., 2001; Leventhal, 2008). Thus, even in the context of negative affect, the presence of recurrent MDD may decrease risk-taking propensity among SUD patients with PTSD. Alternatively, the reinforcing consequences of risk-taking may be less salient in the context of recurrent MDD, due to deficits in responsiveness to reinforcing contingencies (Der-Avakian & Markou, 2012; Treadway & Zald, 2011). Specifically, the presence of recurrent MDD among SUD patients with PTSD may have resulted in reduced anticipation of reinforcing contingencies associated with risk-taking (Pizzagalli et al., 2009; Smoski et al., 2009), resulting in decreased motivation to engage in risk-taking behavior following the trauma script.

Results must be considered in the context of limitations present. First, findings may not generalize to other clinical or nonclinical populations with PTSD and recurrent MDD. Individuals with SUDs are characterized by higher trait disinhibition, which may translate into an increased vulnerability for risk-taking propensity or the tendency to act impulsively in the context of negative affect (Cyders & Smith, 2008; Dom, D’haene, Hulstijn, & Sabbe, 2006; Hopko et al., 2006; Zucker, Heitzig, & Nigg, 2011). Thus, future research is needed to examine the role of recurrent MDD in risk-taking among non-SUD PTSD populations. Likewise, all participants were in residential SUD treatment and exhibited high rates of co-occurring psychiatric disorders. Thus, it is not clear whether findings would extend to non-treatment seeking or outpatient SUD populations. In addition, although the BART predicts real-world risky behaviors (e.g., Lejuez et al., 2002), the extent to which findings generalize to engagement in risky behaviors outside of a laboratory setting when exposed to a trauma-related cue cannot be determined. The consequences of taking more risks on the BART could be perceived as minimal compared to the more severe consequences of engaging in risky behaviors in the real world. Daily diary or ecological momentary assessment procedures could aid in determining the occurrence and context of risky behaviors outside of a laboratory setting. We also utilized a diagnostic interview designed to assess the DSM-IV diagnostic criteria for PTSD. The symptoms associated with PTSD and the criteria for determining a PTSD diagnosis were modified in the DSM-5 (see APA, 2013). Future studies should attempt to replicate our findings among individuals meeting criteria for DSM-5 PTSD.

It also warrants mention that a categorical approach to identifying participants with and without current PTSD and recurrent MDD may not be the best method for examining the influence of PTSD and MDD pathology on risk-taking. Researchers are increasingly recommending a dimensional approach to understanding psychopathology (Brown & Barlow, 2005). Future studies that approach PTSD and MDD from a dimensional perspective may be better suited to identify the specific severity level at which PTSD symptoms increase the likelihood of risk-taking, as well as the point at which depressive symptoms may counter risk-taking tendencies among individuals with PTSD. Likewise, it is important to consider that our findings may be capturing the influence of non-specific symptoms that overlap between PTSD and MDD diagnoses. For example, studies have provided evidence of a dysphoria factor in current conceptualizations of PTSD that is comprised of symptoms (e.g., anhedonia, sleep problems, concentration problems, irritability) that are common to mood and anxiety pathology more broadly (for a review, see Elhai & Palmieri, 2011). This dysphoria factor embedded in the symptoms of PTSD may account for the high co-occurrence between PTSD and MDD (Biehn et al., 2013; Contractor, Greene, Dolan, & Elhai, 2018; Elhai et al., 2015). Future studies would benefit from examining the influence of both disorder-specific and shared symptoms of PTSD and MDD on risk-taking propensity to clarify the unique forms of internalizing and externalizing pathology that may increase or decrease the likelihood of risk-taking in the context of emotional distress. Given our proposition that the lower levels of risk-taking among participants with PTSD and recurrent MDD (relative to those with PTSD and no recurrent MDD) may be due to deficits in responsiveness to reinforcing contingencies, the presence or absence of anhedonia may be especially important to consider.

Results highlight the importance of considering the presence or absence of recurrent MDD in research and/or clinical work with SUD patients with PTSD, given its potential influence on risk-taking in different contexts. Consideration of this and other moderators may provide a more nuanced understanding of the factors that contribute to risk-taking among SUD patients with PTSD, as well as lead to more personalized interventions. First, given the heterogeneous nature of PTSD, as well as the increased likelihood of co-occurring psychiatric disorders among individuals with co-occurring PTSD-SUD, results speak to the importance of assessing for the presence of both specific and non-specific symptoms of PTSD and co-occurring emotional disorders that may play a role in the expression of maladaptive behaviors within PTSD. Such a comprehensive assessment of these symptoms may inform the selection of personalized interventions that effectively address a patient’s unique symptom presentation and risk profile. For example, results suggest that interventions focused on teaching patients strategies to control impulsive behaviors may be less relevant for PTSD-SUD patients with (vs. without) recurrent MDD. Among those with recurrent MDD, clinicians should be attuned to fluctuation in patients’ depressive symptoms over time, given that increases or decreases in depressive symptoms may alter vulnerability for risk-taking behavior. For example, symptoms experienced during a depressive episode (e.g., anhedonia, low energy) may contribute to reduced risk-taking. However, as symptoms improve, risk-taking behavior may be perceived as less effortful and more potentially rewarding. Finally, although higher levels of trait impulsivity have been found among SUD patients with PTSD (Weiss, Tull, Anestis, & Gratz, 2013), results of this study suggest that this impulsivity may be expressed only within certain contexts. As such, there is a need to evaluate the specific context in which risk-taking behaviors occur.

Highlights.

  • The co-occurrence of PTSD and SUDs is associated with greater risk-taking behavior.

  • Recurrent major depression (MDD) may moderate this association.

  • Risk-taking assessed after a neutral and trauma script.

  • PTSD-MDD associated with lower risk-taking post-trauma script than PTSD alone.

  • PTSD-MDD had lesser risk-taking from neutral to trauma script than PTSD alone.

  • Assessing MDD may identify PTSD patients at greater/lesser risk for risky behaviors.

Acknowledgements

This study was funded in part by R21 DA030587, awarded to Dr. Tull from the National Institute on Drug Abuse of the National Institutes of Health. The authors would like to thank the Mississippi State Hospital Chemical Dependence Units and the Bureau of Alcohol and Drug Services of the Mississippi State Department of Mental Health for their assistance with this study.

This study was supported in part by R21 DA030587 awarded to the final author (MTT) from the National Institute on Drug Abuse of the National Institutes of Health.

Role of Funding Source

The funding source (the National Institute on Drug Abuse of the National Institutes of Health) had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Footnotes

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Conflict of Interest

All authors have no conflicts of interest to report.

1

Given that only participants with alcohol and/or cocaine dependence were recruited for this study, we also examined whether the presence of alcohol dependence, cocaine dependence, or combined alcohol and cocaine dependence influenced the observed outcomes. Alcohol/cocaine dependence did not interact with script, PTSD, recurrent MDD, or any combination of these variables to influence risk-taking propensity, Fs (2, 181) < 2.10, ps > .126, fs < .078.

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