Contact: Willemien Langeland, Ph.D.
University of Amsterdam
Addl Contact: Onno van der Hart, Ph.D.
Alcoholism: Clinical & Experimental Research
Both researchers and clinicians can attest to the high co-occurrence of alcoholism and other psychiatric disorders, although the exact contribution of genetic and environmental factors to coexisting psychopathologies remains unclear. Findings published in the March issue of Alcoholism: Clinical & Experimental Research have uncovered the important role that an environment of childhood abuse sexual, physical or both appears to play in the development of psychiatric comorbidity among alcoholic patients.
"Our findings clearly indicate that childhood abuse more specifically, sexual abuse and combinations of sexual and physical abuse is an important factor for the presence of comorbid anxiety disorders in treated alcoholics, particularly regarding social phobia, agoraphobia, and posttraumatic stress disorder," said Willemien Langeland, a freelance trauma researcher at the University of Amsterdam and the Vrije Universiteit in Amsterdam, as well as first author of the study.
Langeland added that, compared with other environmental risk factors, childhood sexual and "dual" abuse contribute independently to a more severe clinical profile, that is, more comorbid diagnoses, in abused versus non-abused alcoholic patients. "This has not been previously demonstrated in treated alcoholics," she said. "In addition, more severe and intrusive forms of early sexual abuse as well as early multiple traumas are associated with a more complex symptom constellation that includes dysthymia (a chronic mood disorder) and suicidality."
"This study and a few others clearly show that seeing alcoholics only as people having an alcohol problem should be a thing of the past," said Onno van der Hart, professor of psychopathology of chronic traumatization in the department of clinical psychology at Utrecht University in the Netherlands. "Very often the alcohol dependency or abuse is an indissoluble part of a history of childhood maltreatment or other adverse life events or conditions, as well as a range of other mental health problems. Insight into such complex patterns will lead to the realization that the simple treatment goal of 'stopping drinking' makes sense only when the overall treatment is geared toward this more complex system of problems."
Researchers collected data during eight months (September 1994 - May 1995) from 155 alcoholics (122 males, 33 females) applying for treatment in a center for substance-use disorders. All study participants were assessed for demographics and treatment history through use of the European Addiction Severity Index; numerous childhood stressors were indexed by the Structured Trauma Interview; and lifetime diagnoses of major depression, dysthymia, panic disorder, social phobia, agoraphobia, generalized anxiety disorder and posttraumatic stress disorder (PTSD) were assessed with the Composite International Diagnostic Interview. Participants were also asked about lifetime suicide attempts.
Alcoholic patients who reported childhood abuse sexual, or sexual and physical also reported social phobia, agoraphobia and PTSD more often than patients with no history of abuse.
"Our study suggests a distinct pattern of psychiatric comorbidity associated with childhood abuse in treatment-seeking alcoholics," said Langeland. "These findings point to the need for greater clinical attention to the role of childhood stressors in the evaluation and treatment of alcoholic patients. They also underline the importance of routine assessment of childhood trauma and possible trauma-related disorders in individuals presenting to alcohol-treatment services. Usually, standard or routine screening procedures do not include possible trauma-related symptoms such as PTSD, leading to under-diagnosis of this disorder."
Van der Hart concurred: "It should be/become standard procedure that diagnostic evaluation of patients seeking treatment for alcohol or other substance abuse or dependence includes the wide range of DSM-IV Axis I and Axis II diagnoses," he said. "Also, careful inquiries regarding lifetime trauma and other adverse events seem mandatory."
Although this study's sample size of men was much greater than the sample size of women, Langeland said it is likely that gender may influence the way that alcohol problems and a co-occurring psychiatric disorder are related. "For example," she said, "there is some evidence suggesting that women may be at higher risk than men to the form of comorbidity in which the PTSD develops first. There is also a growing body of literature, both clinical and preclinical, that supports the notion of higher stress sensitivity in females under both acute and chronic conditions."
In addition, said Van der Hart, "it may well be that many female patients with alcohol dependence or abuse seek treatment in, or are referred to, more general mental-health centers. Perhaps their comorbid disorders, such as depression and anxiety disorders, as well as their trauma history (females report higher degrees of sexual abuse history), are more in the foreground, with the alcohol problems regarded as part of this overall clinical picture. Given this possibility, in future, research patients should also be recruited from other mental-health centers than these specialized substance-use treatment centers."
Both Langeland and Van der Hart noted that these findings raise questions about the use of alcohol as a form of self-medication to mitigate the negative psychological consequences of earlier abuse.
"PTSD appears to be a particularly important factor for alcohol problems in women who have experienced childhood sexual or physical abuse," said Langeland.
"Given the fact that a considerable proportion of alcoholics report a history of childhood trauma and adverse events that include childhood physical and/or sexual abuse, as well as maternal dysfunction, which may point to neglect," added Van der Hart, "studies should investigate whether the use of alcohol or other substances may be a form of coping or self-soothing. In addition, future studies, like the current one, should not only focus on one type of trauma, such as childhood sexual abuse, but should take the whole range of adverse life events and conditions into account."
Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. Co-authors of the ACER paper included: Nel Draijer of the Department of Psychiatry at the Vrije Universiteit in Amsterdam; and Wim van den Brink of the Amsterdam Institute for Addiction Research and the Academic Medical Center at the University of Amsterdam. The study was funded by the Dutch Ministry of Welfare, Public Health & Cultural Affairs and the Ministry of Education & Science within the framework of the Health Research Incentive Program.
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