An examination of attentional control on posttraumatic stress symptoms and problematic alcohol use

Highlights

• Attentional control mediated trauma symptoms and alcohol use.

• Trauma symptoms did not mediate attentional control and alcohol use.

• This specificity informs trauma-related interventions aiming to reduce alcohol use.

• Results were derived from cross-sectional data; causal inference cannot be determined.

Abstract

Trauma-exposed individuals, specifically those with higher posttraumatic stress symptoms (PTSS), are at elevated risk of developing alcohol-related problems. One mechanism via which PTSS may contribute to problematic alcohol use is poor attentional control (AC). AC theory suggests that increases in PTSD-related distress will reduce AC, which could then yield greater problematic alcohol use. An alternative path suggests poor AC amplifies PTSS, thereby promoting alcohol abuse. To date, no research has simultaneously evaluated these two pathways. Trauma exposed participants (N = 339) completed self-report measures on trauma related symptoms, AC, and alcohol use. Cross-sectional analyses tested direct effects of PTSS and AC on problematic alcohol use as well as indirect effects of PTSS on alcohol use via AC and AC on alcohol use via PTSS. Results revealed AC mediated the relationship between PTSS and problematic alcohol use, however PTSS did not mediate the relationship between AC and alcohol use. Current results demonstrate specificity for AC as a mediator in the relationship between PTSS and alcohol use. Future work is needed to determine if the observed statistical mediation effects extend to inform causal models of posttraumatic stress disorder (PTSD) and AUD comorbidity, and if intervening on AC mitigate PTSD and AUD symptomology.

Introduction

Problematic alcohol use is a pervasive and debilitating disorder characterized by excessive use and dependence on alcohol that interferes with daily functioning (American Psychiatric Association, 2013). Approximately 88,000 people die annually from causes related to alcohol, which is the third most preventable cause of death in the United States (Center for Disease Control & Prevention, 2013). Notably, the risk for developing alcohol abuse is particularly high in individuals exposed to a traumatic event (Breslau, Davis, Peterson & Schultz, 1997; McFarlane, 1998; Stewart, 1996). Individuals with more posttraumatic stress symptoms (PTSS), which include intrusive memories, avoidance of relevant cues, persistent negative moods, and hypervigilance resulting from a traumatic experience (American Psychiatric Association, 2013), have been found to exhibit more problems related to alcohol than those with fewer PTSS (Kaysen et al., 2014; Simpson, Stappenbeck, Luterek, Lehavot & Kaysen, 2014; Stewart, Conrod, Pihl & Dongier, 1999). As a result, it is particularly important that research within this domain focus on identifying mechanisms that increase the risk of developing alcohol problems within trauma-exposed individuals.

Attentional control (AC) is one mechanism potentially linking PTSS and alcohol abuse. AC is a multi-faceted construct of executive functioning, reflecting an individual's ability to flexibly orient and shift their attention (Derryberry & Reed, 2002). In addition to orienting and shifting, AC is responsible for maintaining attention toward goal-relevant tasks and helps inhibit shifting attention toward goal-irrelevant tasks (Eysenck, Derakshan, Santos & Calvo, 2007). External or internal stimuli entering the perception and working memory of an individual may also be monitored via AC (Miyake et al., 2000). AC is also conceptualized as a component of a broader construct titled effortful control (Eisenberg, Smith, Sadovsky & Spinrad, 2004), which is composed of an executive attention system and a behavioral control system (or inhibitory control).

Importantly, previous research suggests that deficits in top-down factors of executive functioning, such as AC, impart a greater risk of developing alcohol related disorders (Day, W Kahler, C Ahern & S Clark, 2015; Giancola & Moss, 1998). Specifically, alcohol use and dependence may stem from individuals who have difficulty disengaging their attention to alcohol cues (see Field & Cox, 2008 for a review). For instance, problematic alcohol users take longer to shift their attention away from alcohol cues compared to non-problematic users (Sharma, Albery & Cook, 2001). Additionally, Cox, Hogan, Kristian and Race (2002) found the ability to disengage attention from alcohol-related stimuli prospectively predicted whether alcohol abstainers would relapse. Thus, a diminished capacity to disengage attention from alcohol cues appears to be implicated in problematic alcohol use.

Poor AC has also been linked with elevated PTSS, however there is evidence that each factor may contribute to one another via a transactive risk relationship (Borsboom & Cramer, 2013; Clark, Watson & Mineka, 1994; Schmidt, Lerew & Joiner, 2000), in which AC and PTSS contribute to one another, eventually resulting in alcohol problems. First, it is plausible that experiencing more PTSS may lead to diminished AC. Specifically, AC theory (Eysenck et al., 2007) posits that anxiety decreases an individual's overall AC due to an imbalance of the stimulus driven and goal-directed systems of attention. Attention that is normally allocated towards goal-oriented tasks is instead directed towards salient, threat-related stimuli or stimuli that may relieve the source of anxiety, such as alcohol cues. Consistent with this model, individuals with more PTSS following a trauma exhibit difficulty disengaging their attention away from threat-related stimuli (Foa, Feske, Murdock, Kozak & McCarthy, 1991; Pineles, Shipherd, Welch & Yovel, 2007). Although there are, to our knowledge, no studies demonstrating difficulty disengaging attention from alcohol cues as a function of PTSS, there is tangential evidence suggesting that acute stress may facilitate attention bias towards alcohol cues among users with high coping motives (Field & Powell, 2007), although this study did not differentiate between facilitated attention or attentional disengagement. Taken together, these findings provide preliminary support for AC as a mediator linking greater PTSS and problematic alcohol use.

Alternatively, AC deficits may directly contribute to greater severity of trauma-related symptoms (Aupperle, Melrose, Stein & Paulus, 2012). Specifically, Aupperle et al. (2012) posit AC difficulties influence PTSS by disallowing effective disengagement from the symptoms associated with a trauma. For instance, trauma-exposed individuals with lower AC may have more difficulty shifting their attention away from intrusive reminders. Indeed, previous research shows that deficits in AC are associated with PTSS severity (Bardeen & Orcutt, 2011; Schoorl, Putman, Van Der Werff & Van Der Does, 2014). For instance, Bardeen, Fergus and Orcutt (2015) found low AC at a baseline measurement predicted elevated PTSS at one-month follow-up in participants who experienced a traumatic event. Their results provide evidence that greater AC acts as a buffer against PTSS by allowing individuals to effectively disengage their attention from symptom-related distress, which serves to lower sympathetic arousal and habituate to negative symptom reactions. Although Bardeen et al. (2015) demonstrate AC interacts with trauma exposure to predict PTSS, it is plausible that deficits in AC may exacerbate PTSS in trauma-exposed individuals (Aupperle et al., 2012), however this has yet to be empirically tested.

While there is a plethora of research individually linking AC and PTSS to more alcohol use, research has yet to compare the interplay between AC and PTSS on consumption. As previously outlined, current theoretical and empirical work support an increase in alcohol use via two distinct pathways between AC and PTSS. First, elevated PTSS may negatively influence AC, leading to deficits in the ability to disengage from alcohol-related cues, thereby increasing use (Eysenck et al., 2007; Pineles et al., 2007). Alternatively, low AC may make it more difficult to disengage attention away from trauma-related symptoms, which would then increase alcohol use to dampen the distress associated with PTSS (Aupperle et al., 2012; Bardeen et al., 2015). Although both pathways may be plausible, to the authors’ knowledge research has yet to directly compare each pathway and their influence on problematic alcohol use.

Theoretical frameworks suggest two ways in which PTSS and AC can influence alcohol use: elevated PTSS may lower AC, which then increases alcohol use, or low AC may lead to elevated PTSS, thereby increasing use. The current study aimed to be the first to examine these two non-mutually exclusive pathways explaining the inter-relations between PTSS, AC, and problematic alcohol use. First, in line with AC theory (Eysenck et al., 2007) we hypothesized finding a significant indirect effect of PTSS on problematic alcohol use via worse AC. Second, given research suggesting that worse AC predicts greater PTSS (Albanese et al., 2018; Aupperle et al., 2012; Bardeen et al., 2015) and alcohol use (Field & Eastwood, 2005), we hypothesized finding a significant indirect effect of AC on alcohol problems via PTSS.