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Trauma and
Alcoholism
By Colleen M. Farrelly
Alcoholism and Trauma
• Trauma as a risk factor
o Common experience for soldiers
and civilians in United States
• 25-50% of adolescents have
experienced 1+ traumatic
event
• 50-75% of adults
o Childhood, adulthood, both
o Post-traumatic stress disorder and
relapse link found in veteran
populations
o Trauma cycle (more likely to
experience again if experienced
once)
o Worse alcoholism treatment
response for those with PTSD
• Alcoholism affects roughly 7%
of the United States population
at a given time.
o Higher lifetime prevalence
o Treatment efficacy lower for earlier-
onset disease
• Genetic risk
o GWAS identification
• DRD2, ADH1B, GABRA2, ALDH2,
ADH4, AUTS2, MAOA, 5-HTTLPR
o Evidence of genetic link to early-onset
alcoholism
o Twin studies of Vietnam veterans and
PTSD
• Environmental risk
o Age, gender, age of first use
o Trauma
• Civilians and returning veterans of
OIF/OEF
Specific Aims
• Aim 1
o To examine which traumatic experience types are
associated with alcoholism
• Childhood physical or sexual abuse
• Adulthood assault, non-assault, or sexual trauma
• Aim 2
o To examine whether childhood trauma predicts age of
onset of alcoholism
• Childhood physical abuse
• Childhood sexual abuse
Measurements
• Other environmental
variables
• Demographics
• Age
• Income
• Education level
• Size of childhood town
• Use of alcohol
• Onset of symptoms
• Diagnosis
• Family history
• Mother and father history of
alcohol abuse and dependence
• Trauma Types
• Childhood physical abuse
• Hurt the next day or had to visit
doctor
• Broken bones, bruises, scalding,
burns inflicted by an adult
• Childhood sexual abuse
• Before 16 sexual contact, including
touching and intercourse with
someone 5+ years older
• Adult non-assault trauma
• Natural disasters
• Adult assault trauma
• Military combat, legal definition of
assault
• Adult sexual assault
• Attempted or completed
• Forced unwanted sexual contact
Sample
• Median education: 1 year of
college
• Median income: $20,000-
$29,000
• Family history of alcoholism
o 11 reported maternal alcoholism
o 19 reported paternal alcoholism
• Trauma history
o 52.1% reported a positive history of
trauma
o 25.7% reported more than 1 type of
trauma
o Adulthood non-assault trauma most
common
• Participants from
Collaborative Studies on
Genetics of Alcoholism
Study
o Case-Control
• 167 Caucasian adults
• 85 cases, 82 controls
o Case definition: DSM-IV criteria
met at some point during lifetime
• 84 women, 83 men
• Ages 18-70 years,
mean=41 years
Analysis
• Aim 1
o Logistic regression models for each trauma type, as well as
logistic regression on total number of trauma types experienced
• Aim 2
o Kaplan-Meier curve and log-rank test of proportional hazards
assumption
o Univariate Cox regression for relative risk
o Multivariate Cox regression adjusting for family history of
alcoholism and demographic factors
Results: Aim 1 Regression Models
* p<0.05, ** p<0.01, *** p<0.001 under Bonferroni correction. Significant predictors
include any other significant factors identified in the logistic regression model.
.
Regression
Trauma
Number (%)
Reporting
Trauma
Wald X2 Odds Ratio
(OR)
95% CI of OR p-value Significant
Predictors
Childhood
Physical
Abuse
33 (19.8%) 7.84 6.68 1.77-25.27 0.005** Education*,
Income***
Childhood
Sexual Abuse
38 (22.8%) 11.86 8.83 2.56-30.47 <0.001*** Education*,
income***,
Gender*
Adulthood
Non-Assault
50 (30.0%) 3.14 2.45 0.91-6.61 0.076 Income***,
Education*
Adulthood
Physical
22 (13.2%) 7.93 12.03 2.13-67.93 0.005** Income***
Adulthood
Sexual
15 (9.0%) 2.99 4.67 0.81-26.84 0.084 Education*,
Income***
Total Trauma 87 (52.1%)
reporting 1+
16.58 Significant
for 0 vs. 1+
traumas
Significant for
0 vs. 1+
traumas
<0.001*** Education*,
Income***
Aim 2: Age to Onset of Cases
Case Onset Quantiles
Percent Point
Estimate
95% Confidence Interval
[Lower Upper)
75% 30 28 33
50% 23 22 26
25% 20 19 21
Kaplan-Meier Survival Curves by Childhood
Physical Abuse Status
Kaplan-Meier Survival Curves by Childhood
Sexual Abuse Status
Summary of Univariate and Multivariate Cox
Regression Models
Log-rank
X2
p-
value
Univariate
Hazard Ratio
(95% CI)
Multivariate
Hazard
Ratio (95%
CI)
Other
Significant
Predictors
Physical
Abuse
35.67 <0.001 3.87 (2.41-
6.24)
2.14 (1.27-
3.61)
Age,
Education,
Gender,
Paternal
History
Sexual
Abuse
31.05 <0.001 3.51 (2.20-
5.61)
2.71 (1.62-
4.55)
Age,
Education,
Gender,
Income
Genetic Risk
Log-rank
X2
p-
value
Univariate
Hazard Ratio
(95% CI)
Maternal
History
17.36 <0.001 3.80 (1.94-
7.43)
Paternal
History
22.88 <0.001 3.62 (2.06-
6.33
• Possible more
complicated model
of trauma, genetic
risk, and
demographic factors
• Future work to
examine
interactions and
mediation planned
Discussion of Results
• Both childhood traumas
increased risk of earlier-
onset alcoholism
o Adjusted relative risk >2.0
• Also found strong family
history association with
possible complex
relationship to risk
o Suggests a genetic component to
age-of-onset with physical trauma
o Further study needed to test age-
of-onset and specific single
nucleotide polymorphisms
• Trauma related to
alcoholism for many
types of trauma
• Number of types of
trauma showed no dose-
response
o But higher odds ratios for no
trauma vs. increasing number of
traumas
• Important to consider in
prevention and treatment
of alcoholism
Limitations/Next Steps
Limitations Future Studies
• No data on frequency or severity
of traumatic events
o Previous research suggests importance of
these
• No data on diagnosed PTSD
o Numerous studies of PTSD and alcoholism
risk in combat veterans
• Case-control nature of this study
• Small sample size
• Caucasian sample
• No genomic data used
• Fairly simple statistical methods
that may miss complex
interactions between risk
factors.
• Genomic and gene x
environment studies of
alcoholism risk and age-of-onset
o Few/no existing studies on this
• Diverse population
• Civilian and military populations
o Different types of traumatic events
o Civilian assaults vs. combat
• Utilizing more information about
types, frequencies, and severity
of traumatic events
• Use of machine-learning-based
survival analysis tools
References• Begleiter H, Reich T, Hesselbrock V, Porjesz B, Li TK,
Schuckit MA, Edenberg HJ, Rice JP (1995): The
Collaborative Study on the Genetics of Alcoholism. The
genetics of alcoholism. Alcohol Health Res World 19: 228–
236.
• Sinha, Rajita, et al. "Effects of adrenal sensitivity, stress-
and cue-induced craving, and anxiety on subsequent
alcohol relapse and treatment outcomes." Archives of
general psychiatry (2011): archgenpsychiatry-2011.
• Cloninger, C. Robert, Michael Bohman, and Soren
Sigvardsson. "Inheritance of alcohol abuse: Cross-fostering
analysis of adopted men." Archives of general psychiatry
38.8 (1981): 861.
• Cloninger, C. Robert, et al. "Genetic heterogeneity and the
classification of alcoholism." Advances in alcohol &
substance abuse 7.3-4 (1988): 3-16.
• Johnson, Bankole A., et al. "Age of Onset as a
Discriminator Between Alcoholic Subtypes in a
Treatment‐Seeking Outpatient Population." The American
Journal on Addictions 9.1 (2010): 17-27.
• Jacobson, Isabel G., et al. "Alcohol use and alcohol-related
problems before and after military combat deployment."
JAMA: the journal of the American Medical Association
300.6 (2008): 663-675.
• Coffey, Scott F., et al. "Changes in PTSD symptomatology
during acute and protracted alcohol and cocaine
abstinence." Drug and alcohol dependence 87.2 (2007):
241-248.
• McFarlane, Alexander C. "Epidemiological evidence about
the relationship between PTSD and alcohol abuse: the
nature of the association." Addictive Behaviors 23.6 (1998):
813-825.
• Grant, Bridget F., and Deborah A. Dawson. "Age at onset
of alcohol use and its association with DSM-IV alcohol
abuse and dependence: results from the National
Longitudinal Alcohol Epidemiologic Survey." Journal of
substance abuse 9.1 (1997): 103-110.
• Hingson, Ralph W., Timothy Heeren, and Michael R.
Winter. "Age at drinking onset and alcohol dependence:
age at onset, duration, and severity." Archives of pediatrics
& adolescent medicine 160.7 (2006): 739.
• Ehlers, Cindy L., et al. "Age at regular drinking, clinical
course, and heritability of alcohol dependence in the San
Francisco family study: a gender analysis." The American
Journal on Addictions 19.2 (2010): 101-110.
• Edenberg, Howard J., et al. "Genome‐Wide Association
Study of Alcohol Dependence Implicates a Region on
Chromosome 11." Alcoholism: Clinical and Experimental
Research 34.5 (2010): 840-852.
• Treutlein, Jens, et al. "Genome-wide association study of
alcohol dependence." Archives of general psychiatry 66.7
(2009): 773.
• Treutlein, Jens, and Marcella Rietschel. "Genome-wide
association studies of alcohol dependence and substance
use disorders." Current psychiatry reports 13.2 (2011): 147-
155.

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Trauma and Alcoholism: Risk and Resilience

  • 2. Alcoholism and Trauma • Trauma as a risk factor o Common experience for soldiers and civilians in United States • 25-50% of adolescents have experienced 1+ traumatic event • 50-75% of adults o Childhood, adulthood, both o Post-traumatic stress disorder and relapse link found in veteran populations o Trauma cycle (more likely to experience again if experienced once) o Worse alcoholism treatment response for those with PTSD • Alcoholism affects roughly 7% of the United States population at a given time. o Higher lifetime prevalence o Treatment efficacy lower for earlier- onset disease • Genetic risk o GWAS identification • DRD2, ADH1B, GABRA2, ALDH2, ADH4, AUTS2, MAOA, 5-HTTLPR o Evidence of genetic link to early-onset alcoholism o Twin studies of Vietnam veterans and PTSD • Environmental risk o Age, gender, age of first use o Trauma • Civilians and returning veterans of OIF/OEF
  • 3. Specific Aims • Aim 1 o To examine which traumatic experience types are associated with alcoholism • Childhood physical or sexual abuse • Adulthood assault, non-assault, or sexual trauma • Aim 2 o To examine whether childhood trauma predicts age of onset of alcoholism • Childhood physical abuse • Childhood sexual abuse
  • 4. Measurements • Other environmental variables • Demographics • Age • Income • Education level • Size of childhood town • Use of alcohol • Onset of symptoms • Diagnosis • Family history • Mother and father history of alcohol abuse and dependence • Trauma Types • Childhood physical abuse • Hurt the next day or had to visit doctor • Broken bones, bruises, scalding, burns inflicted by an adult • Childhood sexual abuse • Before 16 sexual contact, including touching and intercourse with someone 5+ years older • Adult non-assault trauma • Natural disasters • Adult assault trauma • Military combat, legal definition of assault • Adult sexual assault • Attempted or completed • Forced unwanted sexual contact
  • 5. Sample • Median education: 1 year of college • Median income: $20,000- $29,000 • Family history of alcoholism o 11 reported maternal alcoholism o 19 reported paternal alcoholism • Trauma history o 52.1% reported a positive history of trauma o 25.7% reported more than 1 type of trauma o Adulthood non-assault trauma most common • Participants from Collaborative Studies on Genetics of Alcoholism Study o Case-Control • 167 Caucasian adults • 85 cases, 82 controls o Case definition: DSM-IV criteria met at some point during lifetime • 84 women, 83 men • Ages 18-70 years, mean=41 years
  • 6. Analysis • Aim 1 o Logistic regression models for each trauma type, as well as logistic regression on total number of trauma types experienced • Aim 2 o Kaplan-Meier curve and log-rank test of proportional hazards assumption o Univariate Cox regression for relative risk o Multivariate Cox regression adjusting for family history of alcoholism and demographic factors
  • 7. Results: Aim 1 Regression Models * p<0.05, ** p<0.01, *** p<0.001 under Bonferroni correction. Significant predictors include any other significant factors identified in the logistic regression model. . Regression Trauma Number (%) Reporting Trauma Wald X2 Odds Ratio (OR) 95% CI of OR p-value Significant Predictors Childhood Physical Abuse 33 (19.8%) 7.84 6.68 1.77-25.27 0.005** Education*, Income*** Childhood Sexual Abuse 38 (22.8%) 11.86 8.83 2.56-30.47 <0.001*** Education*, income***, Gender* Adulthood Non-Assault 50 (30.0%) 3.14 2.45 0.91-6.61 0.076 Income***, Education* Adulthood Physical 22 (13.2%) 7.93 12.03 2.13-67.93 0.005** Income*** Adulthood Sexual 15 (9.0%) 2.99 4.67 0.81-26.84 0.084 Education*, Income*** Total Trauma 87 (52.1%) reporting 1+ 16.58 Significant for 0 vs. 1+ traumas Significant for 0 vs. 1+ traumas <0.001*** Education*, Income***
  • 8. Aim 2: Age to Onset of Cases Case Onset Quantiles Percent Point Estimate 95% Confidence Interval [Lower Upper) 75% 30 28 33 50% 23 22 26 25% 20 19 21
  • 9. Kaplan-Meier Survival Curves by Childhood Physical Abuse Status
  • 10. Kaplan-Meier Survival Curves by Childhood Sexual Abuse Status
  • 11. Summary of Univariate and Multivariate Cox Regression Models Log-rank X2 p- value Univariate Hazard Ratio (95% CI) Multivariate Hazard Ratio (95% CI) Other Significant Predictors Physical Abuse 35.67 <0.001 3.87 (2.41- 6.24) 2.14 (1.27- 3.61) Age, Education, Gender, Paternal History Sexual Abuse 31.05 <0.001 3.51 (2.20- 5.61) 2.71 (1.62- 4.55) Age, Education, Gender, Income
  • 12. Genetic Risk Log-rank X2 p- value Univariate Hazard Ratio (95% CI) Maternal History 17.36 <0.001 3.80 (1.94- 7.43) Paternal History 22.88 <0.001 3.62 (2.06- 6.33 • Possible more complicated model of trauma, genetic risk, and demographic factors • Future work to examine interactions and mediation planned
  • 13. Discussion of Results • Both childhood traumas increased risk of earlier- onset alcoholism o Adjusted relative risk >2.0 • Also found strong family history association with possible complex relationship to risk o Suggests a genetic component to age-of-onset with physical trauma o Further study needed to test age- of-onset and specific single nucleotide polymorphisms • Trauma related to alcoholism for many types of trauma • Number of types of trauma showed no dose- response o But higher odds ratios for no trauma vs. increasing number of traumas • Important to consider in prevention and treatment of alcoholism
  • 14. Limitations/Next Steps Limitations Future Studies • No data on frequency or severity of traumatic events o Previous research suggests importance of these • No data on diagnosed PTSD o Numerous studies of PTSD and alcoholism risk in combat veterans • Case-control nature of this study • Small sample size • Caucasian sample • No genomic data used • Fairly simple statistical methods that may miss complex interactions between risk factors. • Genomic and gene x environment studies of alcoholism risk and age-of-onset o Few/no existing studies on this • Diverse population • Civilian and military populations o Different types of traumatic events o Civilian assaults vs. combat • Utilizing more information about types, frequencies, and severity of traumatic events • Use of machine-learning-based survival analysis tools
  • 15. References• Begleiter H, Reich T, Hesselbrock V, Porjesz B, Li TK, Schuckit MA, Edenberg HJ, Rice JP (1995): The Collaborative Study on the Genetics of Alcoholism. The genetics of alcoholism. Alcohol Health Res World 19: 228– 236. • Sinha, Rajita, et al. "Effects of adrenal sensitivity, stress- and cue-induced craving, and anxiety on subsequent alcohol relapse and treatment outcomes." Archives of general psychiatry (2011): archgenpsychiatry-2011. • Cloninger, C. Robert, Michael Bohman, and Soren Sigvardsson. "Inheritance of alcohol abuse: Cross-fostering analysis of adopted men." Archives of general psychiatry 38.8 (1981): 861. • Cloninger, C. Robert, et al. "Genetic heterogeneity and the classification of alcoholism." Advances in alcohol & substance abuse 7.3-4 (1988): 3-16. • Johnson, Bankole A., et al. "Age of Onset as a Discriminator Between Alcoholic Subtypes in a Treatment‐Seeking Outpatient Population." The American Journal on Addictions 9.1 (2010): 17-27. • Jacobson, Isabel G., et al. "Alcohol use and alcohol-related problems before and after military combat deployment." JAMA: the journal of the American Medical Association 300.6 (2008): 663-675. • Coffey, Scott F., et al. "Changes in PTSD symptomatology during acute and protracted alcohol and cocaine abstinence." Drug and alcohol dependence 87.2 (2007): 241-248. • McFarlane, Alexander C. "Epidemiological evidence about the relationship between PTSD and alcohol abuse: the nature of the association." Addictive Behaviors 23.6 (1998): 813-825. • Grant, Bridget F., and Deborah A. Dawson. "Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: results from the National Longitudinal Alcohol Epidemiologic Survey." Journal of substance abuse 9.1 (1997): 103-110. • Hingson, Ralph W., Timothy Heeren, and Michael R. Winter. "Age at drinking onset and alcohol dependence: age at onset, duration, and severity." Archives of pediatrics & adolescent medicine 160.7 (2006): 739. • Ehlers, Cindy L., et al. "Age at regular drinking, clinical course, and heritability of alcohol dependence in the San Francisco family study: a gender analysis." The American Journal on Addictions 19.2 (2010): 101-110. • Edenberg, Howard J., et al. "Genome‐Wide Association Study of Alcohol Dependence Implicates a Region on Chromosome 11." Alcoholism: Clinical and Experimental Research 34.5 (2010): 840-852. • Treutlein, Jens, et al. "Genome-wide association study of alcohol dependence." Archives of general psychiatry 66.7 (2009): 773. • Treutlein, Jens, and Marcella Rietschel. "Genome-wide association studies of alcohol dependence and substance use disorders." Current psychiatry reports 13.2 (2011): 147- 155.