Alcohol Dependence Among Trauma-Exposed Individuals: Pathways Between Traumatic Incidences, Alcohol Use, Attentional and Autonomic Processes, and Self-Efficacy

Background and Purpose: Individuals exposed to traumatic stressors are at increased risk for the development of alcohol use disorders. Persistent use of alcohol often results in attentional bias toward alcohol cues (i.e., automatic and involuntary capture of attention by cues associated with past drinking episodes) and psychophysiological reactivity such as changes in heart rate variability (HRV). Under stressful and traumatic conditions, these attentional and autonomic processes are often exacerbated and may evoke alcohol craving, which may in turn result in drinking as a means of alleviating distress. Maladaptive coping through alcohol use is perpetuated among individuals with a low self-efficacy, who feel unable to resist drinking in high risk situations. Few studies have examined interrelations among attentional and autonomic processes linking traumatic stress to alcohol self-efficacy. This study of alcohol dependent adults aimed to examine the pathways by which exposure to traumatic incidences, attentional and autonomic regulation, and self-efficacious behaviors interact to motivate sustained alcohol dependence.

Methods: Data were collected in a single assessment session with alcohol dependent adults (n=58), who had resided in a residential treatment facility. Participants completed a series of standardized psychosocial instruments, an affect-modulated cue-reactivity protocol measuring the low-to-high frequency ratio of heart rate variability (HRV) responses to stress-primed alcohol cues, and a spatial cueing task designed to assess alcohol attentional bias. Multivariate path analysis was employed to test a model in which alcohol attentional bias or HRV reactivity could mediate the relationship between lifetime traumatic incidences and alcohol self-efficacy in relation to alcohol dependence. 

Results: This model exhibited good fit: χ²(8) = 7.91, p = .44, CFI = 1.00, RMSEA = .00 (.00, .15). Results of the multivariate path analysis revealed significant direct effects of levels of lifetime trauma exposure on alcohol attentional bias (β = .32, p < .05), HRV reactivity (β = .27, p < .05), and number of alcohol dependence criteria (β = .29, p < .05). Results also indicated a significant direct effect of number of alcohol dependence criteria on HRV reactivity (β = .56, p < .001). Alcohol attentional bias partially mediated the relationship between lifetime traumatic incidences and alcohol self-efficacy. However, HRV reactivity did not mediate the relationship between lifetime trauma exposure and alcohol self-efficacy.

Conclusions and Implications: Results of the multivariate path analysis indicate that individuals with higher levels of lifetime trauma exposure experience increased attentional bias toward alcohol-related cues, and thereby are less likely to resist the urge to drink alcohol (i.e. alcohol inefficacy). Psychophysiological cue-reactivity that co-occurs with attentional bias toward alcohol is heightened in alcohol dependent individuals with significant trauma. Such individuals may lack insight into their addiction and thus experience discordance between self-awareness and attentional and autonomic indices of addiction. Under stressful situations that intensify alcohol cravings, individuals with heightened alcohol reactivity and compromised insight may be at particular risk for relapse. Substance abuse interventions aiming to disrupt the addiction cycle should focus on increasing self-awareness and self-efficacy so that alcohol dependent individuals can recognize their maladaptive coping tendencies in response to high-risk situations.