The influence of posttraumatic stress disorder and recurrent major depression on risk-taking propensity following trauma script exposure among patients with substance use disorders

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.

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.

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 et al., 2012, Najavits et al., 2007, Ouimette et al., 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 and Tull, 2010, Weiss et al., 2013, Weiss et al., 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 et al., 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 et al., 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 et al., 2008, Rottenberg et al., 2005). Given evidence that risk-taking behaviors may serve an emotion regulatory function (Tull et al., 2012, Weiss et al., 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 et al., 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 et al., 2004, Paradis et al., 2006, Stordal et al., 2004, Vuorilehto et al., 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.