Addictive Behaviors 50 (2015) 128–134

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Addictive Behaviors

Interactive effects of stress and individual differences on alcohol use and posttraumatic stress disorder among personnel deployed to Guantanamo Bay☆ Gabriel M. De La Rosa ⁎, Eileen M. Delaney, Jennifer A. Webb-Murphy, Scott L. Johnston Naval Center for Combat and Operational Stress Control, United States

a r t i c l e

i n f o

Available online 9 June 2015 Keywords: Posttraumatic stress disorder Alcohol abuse Neuroticism Psychotherapy stigma Resilience Military

a b s t r a c t This study examines the role of factors such as perceived stress, neuroticism, beliefs in psychotherapy stigma, resilience, and demographics in understanding posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) among deployed military personnel. Results show that personnel who screened positive for PTSD were more likely to screen positive for AUD (versus those who did not screen positive for PTSD). Perceived stress, neuroticism, and psychotherapy stigma all have direct multivariate relationships with PTSD symptoms. Moderated regression analyses show that the positive relationship between perceived stress and PTSD symptoms is significantly stronger among those scoring high on neuroticism and psychotherapy stigma. The positive relationship between perceived stress and AUD symptoms is only significant among those scoring high on psychotherapy stigma. Given the moderating role of psychotherapy stigma in the relationship between perceived stress and PTSD symptoms and the relationship between perceived stress and AUD symptoms efforts to reduce the stigma associated with mental health care in the military should be expanded. Also, the current research adds to the literature highlighting the role of neuroticism as a key variable in understanding PTSD. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction 1.1. PTSD definition and prevalence Posttraumatic stress disorder (PTSD) is a reaction to a traumatic event resulting in various symptom clusters. Based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), the symptom clusters consist of re-experiencing the traumatic event, avoidance, and hyperarousal. The more recent publication of DSM-5 (2013) conceptualizes PTSD as having four symptom clusters that include intrusion, avoidance, negative changes in mood or thought, and changes in activity or arousal. For a diagnosis of PTSD, symptoms must be present for more than one month and must impact daily functioning (American Psychiatric Association, 2013). In a nationally representative study, the prevalence rate of PTSD among civilians was estimated at 7.8% (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995) this result was later replicated with a slightly larger representative civilian sample (Kessler et al., 2005). In comparison, the

☆ The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. ⁎ Corresponding author at: 4330 Campus Ave #6, San Diego, CA 92103, United States. Tel.: +1 419 601 1073. E-mail address: [email protected] (G.M. De La Rosa).

http://dx.doi.org/10.1016/j.addbeh.2015.06.016 0306-4603/© 2015 Elsevier Ltd. All rights reserved.

prevalence of PTSD among veterans of the Gulf War and Operation Enduring Freedom/Operation Iraqi Freedom was 10.1% (Kang, Natelson, Mahan, Lee, & Murphy, 2003) and 13.8% (Tanielian & Jaycox, 2008), respectively. Further, a review study found that 5% to 12% of military respondents screened positive for PTSD, while prevalence rates of PTSD among returning service members from Iraq/Afghanistan seeking mental health treatment ranged from as low as 4.2% to much higher rates at 50.0% (Ramchand et al., 2010); however, higher rates have been found with convenience samples or among those with PTSD symptoms prior to deployment. 1.2. Alcohol use disorder definition and prevalence Alcohol use disorder (AUD) is the result of continued consumption of alcohol despite negative consequences to one's life and daily functioning. To meet the diagnostic criteria for AUD, at least two symptoms indicative of problematic use must be present in the last 12 months (American Psychiatric Association, 2013). Several examples of symptoms of problematic alcohol use include: drinking more than intended, failed attempts to reduce alcohol consumption, devoting a great deal of time to alcohol consumption, allowing alcohol use to interfere with other important aspects of life, use of alcohol in inappropriate or dangerous contexts, building up tolerance to alcohol, and experiencing withdrawal symptoms when abstaining from alcohol (American Psychiatric Association, 2013). Among civilian populations,

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the lifetime prevalence of AUD is 17.8% (Hasin, Stinson, Ogburn, & Grant, 2007). The prevalence of alcohol abuse among military samples is estimated between 15% and 20% (Bray & Hourani, 2007). 1.3. Comorbid PTSD and AUD Research has shown that PTSD often occurs along with AUD; for example, in a sample of 5800 individuals, 52% of men and 28% of women with PTSD met criteria for lifetime alcohol misuse/dependence (Kessler et al., 1995). Further, the National Vietnam Veterans Readjustment Study (NVVRS) showed that for those suffering from PTSD, 22% had a current diagnosis of alcohol misuse/dependence and 75% had a lifetime diagnosis of alcohol misuse/dependence (Kulka et al., 1988). Researchers investigating the comorbidity of PTSD and AUD have hypothesized that PTSD and AUD may share many causal or explanatory factors. Brady, Back, and Coffey (2004); McCauley, Killeen, Gros, Brady, and Back (2012) provide a useful review of theoretical and empirical work on comorbid PTSD and AUD. Theories such as the “common factors hypothesis”, the “high-risk hypothesis”, and the “susceptibility hypothesis” suggest that environmental conditions and individual predispositions interact in such a way to bring about comorbid PTSD and AUD (Brady et al., 2004; McCauley et al., 2012). Environmental conditions such as being exposed to numerous stressors or a particularly intense stressful event have been linked to both PTSD and AUD (Brady et al., 2004). Anxiety related personality variables (Reich, 1990) and attitudes toward mental health (Hoge et al., 2004) have also been identified as important correlates of PTSD and/or AUD symptoms. For example, those scoring high on neuroticism tend to experience a greater number of PTSD symptoms (Casella & Motta, 1990) and AUD symptoms (Carney, Armeli, Tennen, Affleck, & O'Neil, 2000) than those scoring low in neuroticism. In addition, attitudes toward psychotherapy relates to PTSD severity among military personnel (Hoge et al., 2004), and civilians who hold negative or pessimistic views of mental health care treatment are more likely to screen positive for AUD (Ten Have et al., 2010). The goal of the present study is to generally identify shared factors that help to explain both PTSD and AUD symptoms. Given the current study focuses on deployed military personnel, variables previously found to be relevant in this context were included in the study. Additional details on the variables examined in the study follows. 1.4. Perceived stress relates to PTSD and alcohol abuse Perceived stress is a construct that reflects the extent to which an individual has experienced aversive events believed to be overwhelming, unpredictable, or uncontrollable (Cohen, Kamarck, & Mermelstein, 1983). Past research shows that perceived stress is a key variable in understanding PTSD or AUD. For example, combat exposed military personnel who were later diagnosed with PTSD reported significantly higher levels of perceived stress than combat exposed military personnel who later screened negative for PTSD (Solomon, Mikulincer, & Hobfoll, 1987). In a large study of military personnel, increases in perceived stress increased the likelihood of respondents engaging in heavy drinking (Bray, Fairbank, & Marsden, 1999). Among civilians exposed to rocket and mortar fire, those who scored high on perceived stress were more likely to report a higher number of PTSD symptoms (Besser, Neria, & Haynes, 2009). Also, civilians who score high on perceived stress also tend to experience a greater number of alcohol-related problems (Tomaka, Morales‐Monks, & Shamaley, 2012).

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process (Enns, Cox, & Clara, 2005). For example, the relationship between trauma exposure and PTSD symptoms is significantly stronger among people scoring high on neuroticism (versus those scoring low on neuroticism) (Casella & Motta, 1990). Also, the relationship between stressors and alcohol consumption is stronger among individuals scoring high on neuroticism (versus individuals scoring low on neuroticism) (Carney et al., 2000). Research with Vietnam War veterans found that negative emotionality mediated the positive relationship between PTSD and alcohol related problems (Miller, Vogt, Mozley, Kaloupek, & Keane, 2006). 1.6. Psychotherapy stigma moderates the stressor–strain relationship Negative or pessimistic attitudes regarding psychotherapy can negatively impact the efficacy of treatment (Addis & Jacobson, 2000). Negative attitudes or stigmas that individuals commonly endorse regarding psychotherapy treatment tend to center around psychotherapy not being helpful, psychotherapy making problems worse, and that psychotherapy is a sign of weakness (Bystritsky et al., 2005). While no study has systematically compared psychotherapy stigma between civilian and military samples, it is apparent that this phenomenon exists in both spheres. For example, primary care patients with a range of anxiety disorders who endorsed psychotherapy stigmas were less likely to use psychotherapy treatment (Bystritsky et al., 2005). Additionally, military service members who screen positive for mental health symptoms endorse more mental health stigma and barriers to mental health care (Hoge et al., 2004). Military stigma is likely more prevalent due to the warrior ethos culture and active duty service members' have more to lose in terms of damages to one's career or opportunity for promotion. At present, there are no published studies specifically investigating the moderating role of psychotherapy stigma in the relationship between perceived stress and mental health outcomes such as PTSD or AUD. However, related research suggests psychotherapy stigma could play a role in how people respond to stressors and mental health symptoms. For example, those who endorse psychotherapy stigma are less likely to use psychotherapy treatment (Bystritsky et al., 2005). Given the well-documented effects of psychotherapy on both PTSD symptom reduction (Sherman, 1998) and in reducing alcohol abuse (Emrick, 1975), personnel who endorse psychotherapy stigma may not utilize effective resources available to deal with stressors and thus may be more susceptible to the development of various types of psychological strain (PTSD and/or AUD). 1.7. Resilience moderates the stressor–strain relationship Research demonstrates that resilience moderates the relationship between stressful events and the development of psychological strain among civilians (Campbell-Sills, Cohan, & Stein, 2006) and moderates the relationship between occupational stress and psychological health among military personnel (Dolan & Adler, 2006). Those who score high on resilience tend to engage in more proactive and healthy forms of coping and are less likely to engage in avoidant forms of coping (Johnson et al., 2008). Typically, those scoring higher on resilience employ adaptive coping strategies in the face of stress, are able to “bounce back” from stressors and develop fewer stress outcomes such as PTSD symptoms (Agaibi & Wilson, 2005) and/or alcohol related problems (Kumpfer, 2002) than those who score low on resilience. 2. Hypotheses

1.5. Neuroticism as a moderator of the stressor–strain relationship The emotionally sensitive nature of the neuroticism personality construct plays a key role in explaining PTSD and substance abuse. A rich body of literature exists documenting the moderating role of neuroticism and negative emotionality in the stressor–strain response

Given the literature reviewed thus far, we anticipate that personnel who screen positive for PTSD will be more likely to also screen positive for AUD. We also expect perceived stress, neuroticism and psychotherapy stigma to positively relate to PTSD and AUD symptoms. We expect resilience to negatively relate to PTSD and AUD symptoms. Further, we

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expect neuroticism, psychotherapy stigma, and resilience to moderate the positive relationship between perceived stress, PTSD symptoms, and AUD symptoms such that the relationships will be stronger among those scoring high on neuroticism, psychotherapy stigma, and those scoring low on resilience. 3. Method 3.1. Research setting and protocol The participants in this study include service members stationed at the detention facility at the Guantanamo Bay Naval Base, operated by Joint Task Force Guantanamo Bay (JTF-GTMO), which was established in 2002 to hold detainees from conflicts associated with the Global War on Terror. This is likely a high stress group. In addition to having the normal deployment-related stressors, such as separation from family and friends, those deployed to JTF-GTMO have occupation-specific stressors related to the nature of working at a detention facility, such as negative public perception of JTF-GTMO detention, threats of violence from detainees, constant psychological warfare, fear of negative allegations from detainees, restricted job autonomy, regular changes in rules, having to be constantly alert and on guard, lack of participation in decision making, and unmet deployment expectations (Johnston, Webb-Murphy, Raducha, & Abou, 2011). Survey data were collected in a group format in 2009. The exact response rate is unavailable because the number of personnel available to participate in the assessment is unknown. However, one of the study authors was on site during data collection and observed that most personnel chose to participate in the assessment. Data were collected as part of a needs assessment then approved for research use by the Institutional Review Board at Naval Medical Center San Diego in 2010 in compliance with all applicable Federal regulations governing human subject research. 3.2. Measures Perceived stress was measured using the Perceived Stress Scale (PSS) (Cohen et al., 1983) which consists of 10 items asking about general perceived stress in the last month. An example item from the PSS scale is: “In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?” Items are scored from 0 (never) to 4 (very often) with reverse scoring on some of the questions. Scores can range from 0 to 40, higher total scores indicate higher perceived stress. At current, no diagnostic cutoffs exist for the PSS. Cronbach's alpha for the scale was .89. Posttraumatic stress disorder symptoms were measured using the PTSD Checklist-Military (PCL-M) (Weathers, Litz, Herman, Huska, & Keane, 1993), consisting of 17 items that correspond to the 17 DSM-IV symptoms of PTSD experienced in the past month resulting from a military-related stressor. An example item from the PCL-M scale is: “Repeated, disturbing dreams of a stressful military experience?” Items are scored from 1 (not at all) to 5 (extremely). Higher scores indicate more PTSD symptoms. Screening positive for PTSD was determined by a total score of 50 or more in addition to the presence of at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptoms that were rated by respondents at the moderate level or above (Hoge et al., 2004). Cronbach's alpha for the scale was .94. Alcohol abuse was measured using a composite scale made up of the four-item CAGE (Cut-down, Annoyed, Guilty, Eye opener) (Ewing, 1984) and two items from the Alcohol Use Disorder Identification Test (AUDIT) (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). The CAGE items were scored in a dichotomous (“yes” or “no”) manner. Because the CAGE items reflect attitudes regarding one's drinking behaviors, two items from the AUDIT were included that ask about the quantity of alcohol consumed. The two AUDIT items used are: “In the past three months, how often have you had a drink containing alcohol?” and “In

the past three months, how many drinks containing alcohol have you had on a typical day when you were drinking?” AUDIT items were scored on a 5-point Likert-type scale. Higher scores on the alcohol abuse composite scale reflect more alcohol consumption. Prevalence of alcohol abuse was determined by a positive response to two or more items on the CAGE scale (Ewing, 1984). Regression analyses were conducted using the six-item alcohol abuse composite scale. To give each item equal weight in the overall alcohol abuse composite scale, all CAGE items that were endorsed as “Yes” were scored as 5 points. The alcohol abuse composite scale is the mean score across the six items (CAGE and AUDIT items). Cronbach's alpha for the six item scale was .78. Resilience was measured using the Response to Stressful Experiences Scale (RSES) (Johnston et al., 2011), a 22-item scale assessing different coping styles. The five different coping styles and example items from each style (in parenthesis) are: active coping (“During and after life's most stressful events, I tend to…take action to fix things”), cognitive flexibility (“…look for creative solutions to the problem”), spirituality (“…meditate or pray”), and self-efficacy (“…know I will bounce back”). Item-level scores range from 0 (not at all like me) to 4 (exactly like me). Researchers using the RSES (e.g., Besterman-Dahan et al., 2012; De La Rosa, Webb-Murphy, & Johnston, 2015; Haase et al., 2014) have aggregated scores of all 22 RSES items to a single resilience score. As such, the current research computes an overall RSES score. Total scores can range from 0 to 88. Higher total scores indicate a more resilient response to stressful events. Cronbach's alpha for the scale was .95. Endorsement of psychotherapy stigma was measured using the eight item Beliefs on Psychotherapy Subscale (BPS) (Bystritsky et al., 2005). Respondents rate the extent to which they agree with several statements about psychotherapy. An example item is: “Being in therapy is a sign of weakness.” Items are scored on a five-point scale ranging from strongly agree to strongly disagree. Scale scores can range from 10 to 50. Higher total scores indicate a pessimistic or distrustful attitude toward psychotherapy. Cronbach's alpha for the scale was .88. Neuroticism was measured using the 12-item neuroticism subscale of the NEO personality inventory (NEO-N) (Costa & McCrae, 1992). Respondents rate the extent to which they agree with several descriptive statements about themselves. An example item from the NEO-N scale is: “I am not a worrier.” Items are scored on a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Respondents rate the extent to which they agree with several statements about themselves. Higher total scores indicate higher levels of neuroticism. Cronbach's alpha for the scale was .83. 3.3. Participants Demographic characteristics of participants are summarized in Table 1. The current sample is made up mostly of men who are young (age 18–24) and at the early stages of their military career (E-4 to E-6). Most participants were serving in the Army or Navy. Ethnicity was not collected. Fifty-seven percent of respondents had not previously deployed, 22% of respondents had been on one deployment previously, and 21% of respondents had been on more than one previous deployment. Most participants (74%) were at the midpoint of their deployment, 20% of the sample were at the beginning of their deployment, and 6% were receiving a post-deployment briefing. 3.4. Analysis To test for a relationship between PTSD and AUD, a chi-square test and a t-test was conducted. Relationships between perceived stress, neuroticism, psychotherapy stigma, resilience, and PTSD symptoms and AUD symptoms were tested via moderated multiple regression (Aiken & West, 1991). Regression models focusing on PTSD symptoms and AUD symptoms were ran separately. Past research shows that age (Brailey, Vasterling, Proctor, Constans, & Friedman, 2007; Green, Grace,

G.M. De La Rosa et al. / Addictive Behaviors 50 (2015) 128–134 Table 1 Sample demographics. Frequency

Percent

Gender Male Female

398 96

80.57 19.43

Branch of service Army Air Force Navy Marines

215 7 265 1

44.06 1.43 54.30 0.20

Rank E1–3 E4–6 E7–9 O1–3 O4–8

139 283 29 27 7

28.66 58.35 5.98 5.57 1.44

Age 18–24 25–29 30–39 40+

208 137 109 32

42.80 28.19 22.43 6.58

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AUD was higher among military personnel screening positive for PTSD (16 of the 45 [36.5%] personnel who screened positive for PTSD also screened positive for AUD) than among personnel screening negative for PTSD (48 of the 442 [10.9%] personnel who screened negative for PTSD screened positive for AUD). A chi-square test shows that those screening positive for PTSD have a significantly higher rate of AUD compared to those who screen negative for PTSD, x 2 (1, n = 487) = 21.82, p b .001. Also, mean alcohol abuse composite scores were significantly higher among personnel screening positive for PTSD (M = 6.16, SD = 3.62) than among personnel not screening positive for PTSD (M = 3.51, SD = 2.85), t (482) = 5.76 p b .001. 4.2. Relations among perceived stress, individual differences, PTSD symptoms, and alcohol abuse symptoms

Lindy, Gleser, & Leonard, 1990; Mennis & Mason, 2012) and gender (Cooper, Russell, Skinner, Frone, & Mudar, 1992; Cottler, Nishith, & Compton, 2001; Mennis & Mason, 2012; Mennis & Mason, 2012) relate to PTSD and AUD. As such, age and gender were included as covariates. For each model, covariates were entered in at step one, followed by explanatory variables at step two, and then the interaction terms were entered at step three. Analyses were performed using SPSS version 21. Scale scores were not calculated for any respondent with missing values on 2 or more items from a given measure. No more than 3% of respondents were missing 2 or more items on a given measure. For regression, t-tests, and chi-square analyses, listwise deletion was used to handle cases with missing values. To test for normality of the data, frequency histograms and Normal Q–Q plots were inspected. With the exception of the alcohol composite scale, all measures appear to be distributed approximately normal. The distribution of the alcohol composite scale is skewed because most respondents endorsed few alcohol problems. 4. Results 4.1. Relations between PTSD and alcohol abuse Overall, 45 out of 498 participants (9.0%) screened positive for PTSD. Sixty-four out of 487 participants (13.1%) screened positive for AUD (sample size differences are due to missing values). The prevalence of

Results of moderated regression models regressing explanatory variables on PTSD symptoms and AUD symptoms appear in Tables 2 and 3, respectively. Figs. 1–3 display interactions as charted by methods described in Aiken and West (1991). Perceived stress, neuroticism, and psychotherapy stigma all positively relate to PTSD symptoms. The positive relationship between perceived stress and PTSD symptoms is stronger among those scoring high on neuroticism and among those scoring high on psychotherapy stigma (see Figs. 1 & 2). Only the perceived stress by psychotherapy stigma interaction term significantly related to AUD symptoms. Fig. 3 suggests a positive relationship between perceived stress and AUD symptoms exists among those scoring high on psychotherapy stigma. The moderated relationship between perceived stress and AUD symptoms was further investigated by examining bivariate correlations between perceived stress and AUD symptoms among participants scoring above and below average (18.87) on BPS. The relationship between perceived stress and AUD symptoms is significant and positive (r = .22, p b .01) for those scoring above average on BPS (n = 243); in contrast, the relationship is nonsignificant (r = .11, p N .05) among those scoring below average on BPS (n = 239). 5. Discussion Analyses show that personnel who screened positive for PTSD were more likely to screen positive for AUD (versus those who did not screen positive for PTSD). These results add to the literature documenting the co-morbidity of PTSD and AUD (Brady et al., 2004). The current study also adds to existing literature in that important correlates of both PTSD and AUD were analyzed among a sample of deployed military personnel. As such, the current study helps to increase the understanding of factors that contribute to both PTSD and AUD (Brady et al., 2004).

Table 2 Results for regression models predicting PTSD symptoms. Model 1

Model 2

Variable

B

SE B

Intercept Age Sex Perceived Stress Scale (PSS) Response to Stressful Experiences Scale (RSES) Neuroticism (NEO-N) Beliefs in Psychotherapy Stigma (BPS) PSS × RSES PSS × NEO PSS × BPS Adjusted R2 F

34.13⁎⁎⁎ −0.23 −1.95

2.25 0.08 1.43

0.02 5.13

β −0.13⁎⁎ −0.06

Model 3

B

SE B

27.44⁎⁎⁎ 0.02 −1.87 4.85 −0.26 3.10 1.68⁎⁎

1.74 0.06 1.10 0.60 0.53 0.59 0.51

0.45 63.44

Note. PSS, NEO, BPS, and RSES were centered at their means; dependent variable = PTSD Checklist-Military; N = 465. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

β 0.01 −0.06 0.39⁎⁎ −0.02 0.25⁎⁎⁎ 0.14⁎⁎

B

SE B

26.47⁎⁎⁎ −0.02 −1.51 4.32 −0.22 2.94 1.51 0.38 2.16 1.62 0.51 58.22

1.62 0.06 1.02 0.56 0.49 0.55 0.47 0.49 0.43 0.41

β −0.01 −0.05 0.35⁎⁎⁎ −0.02 0.24⁎⁎⁎ 0.12⁎⁎ 0.03 0.20⁎⁎⁎ 0.15⁎⁎⁎

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Table 3 Results for regression models predicting alcohol use disorder symptoms. Model 1

Model 2

Variable

B

SE B

Intercept Age Sex Perceived Stress Scale (PSS) Response to Stressful Experiences Scale (RSES) Neuroticism (NEO) Beliefs in Psychotherapy Stigma (BPS) PSS × RSES PSS × NEO PSS × BPS Adjusted R2 F

6.34⁎⁎⁎ −0.01 −0.95

1.16 0.04 0.74

β −0.01 −0.06

0.00 0.89

Model 3

B

SE B

4.70⁎⁎⁎ 0.05 −0.88 0.74 −0.63 0.48 0.40

1.16 0.04 0.73 0.40 0.35 0.40 0.34

β 0.06 −0.06 0.12 −0.10 0.08 0.06

0.07 6.47⁎⁎⁎

B

SE B

β

4.72⁎⁎⁎ 0.04 −0.73 0.61 −0.60 0.51 0.39 0.20 −0.28 0.90 0.08 5.44⁎⁎⁎

1.16 0.04 0.72 0.40 0.35 0.39 0.34 0.35 0.31 0.30

0.05 −0.05 0.10 −0.09 0.08 0.06 0.03 −0.05 0.17⁎⁎

Note. PSS, NEO, BPS, and RSES were centered at their means; N = 465. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

Regression analyses show that perceived stress is directly positively related to PTSD symptoms but not directly related to AUD symptoms. Further, the relationship between perceived stress and PTSD is significantly stronger among those scoring high on psychotherapy stigma. Psychotherapy stigma also moderates the relationship between perceived stress and AUD such that a positive relationship between perceived stress and AUD only exists among those scoring high on psychotherapy stigma. Given past studies have shown that a large proportion of military personnel hold negative attitudes toward psychotherapy and that these attitudes constitute significant barriers to accessing mental health care (Hoge et al., 2004), results of the current study have important implications for the treatment of PTSD and AUD among military personnel. The current research is unable to determine if psychotherapy stigma acted as a barrier to accessing care in the current setting. However, given the noted relationship between attitudes toward psychotherapy and avoiding mental health care in both civilian (Bystritsky et al., 2005) and military samples (Hoge et al., 2004), it is possible that those who endorse these attitudes actively avoid mental health care, even when this care is needed (Bystritsky et al., 2005). Thus, these individuals may be missing out on the benefits of therapy in reducing PTSD symptoms (O'Farrell & Fals-Stewart, 2000) and AUD symptoms (Magill & Ray, 2009). As such, the magnified impact of perceived stress on PTSD and AUD among those scoring high on psychotherapy stigma may, in part, be due to the absence of mental health care. To help alleviate PSTD and AUD symptoms among those scoring high on psychotherapy stigma, anti-stigma campaigns associated with mental health care could be enhanced. Also, less formal means of mental

Low NEO-N

40

health care may be more acceptable to those in the military. For example, “Buddy Aid” is a process by which peers are given training about psychological stress and are encouraged to discuss common stressors with those in their unit and provide both initial “on the ground” assistance and additional resources to more formal treatment if necessary (Adler, Castro, & McGurk, 2009). The “Buddy Aid” model has shown to be helpful, however additional research is needed (Adler et al., 2009). Similar to past research (Enns et al., 2005; Miller et al., 2006) neuroticism emerges as an important variable to understanding the relationship between perceived stress and PTSD symptoms. Neuroticism exhibits both a positive linear relationship with PTSD symptoms and moderates the relationship between perceived stress and PTSD symptoms. The positive relationship between perceived stress and PTSD is stronger among those scoring high on neuroticism. The neuroticism construct is operationalized by items such as “… often feeling tense or jittery” and “…often get angry at the way people treat me” which reflect emotional dispositions that can be especially relevant to understanding PTSD symptoms. The moderating role of neuroticism on the relationship between perceived stress and PTSD symptoms further confirms the role of neuroticism in the relationship between stressors and mental health symptoms (e.g., Enns et al., 2005; Miller et al., 2006). The sensitive and emotionally reactive nature of the neurotic personality helps to explain the development of more PTSD symptoms in response to high levels of perceived stress. Because those who score high in neuroticism may be at greater risk of experiencing PTSD symptoms after exposure to stressful events, it is

High BPS

35

PCL-M Score

35

PCL-M Score

Low BPS

40

High NEO-N

30

25 20 15

30

25 20 15 10

10

5

5

0 Low PSS

0 Low PSS

High PSS

High PSS

Fig. 1. Neuroticism moderates the relationship between perceived stress and PTSD score. Note. PSS = Perceived Stress Scale; NEO-N = neuroticism; PCL-M = PTSD ChecklistMilitary; high and low refer to 1 SD above and below the mean, respectively.

Fig. 2. Psychotherapy stigma moderates the relationship between perceived stress and PTSD score. Note. PSS = Perceived Stress Scale; BPS = beliefs in psychotherapy stigma; PCL-M = PTSD Checklist-Military; high and low refer to 1 SD above and below the mean, respectively.

G.M. De La Rosa et al. / Addictive Behaviors 50 (2015) 128–134 Low BPS

7

High PBS

AUD Score

6

133

it is still possible that participants attempted to present themselves in the best light and underreported things like alcohol abuse or perceived stress.

5

5.2. Conclusions 4 3 2 1 0 Low PSS

High PSS

Fig. 3. Psychotherapy stigma moderates the relationship between perceived stress and alcohol abuse. Note. PSS = Perceived Stress Scale, BPS = beliefs in psychotherapy stigma, high and low refer to 1 SD above and below the mean, respectively.

important to take into consideration the nature of the emotionally sensitive personality when these individuals are in potentially traumatic situations and when attempting to treat those suffering from PTSD. Past research has shown that techniques that focus on enhancing the participants' awareness of their cognitive, behavioral, and emotional responses to stimuli are effective in reducing symptoms related to PTSD (Kearney, McDermott, Malte, Martinez, & Simpson, 2012). These types of treatment tend to focus on empowering people by giving them a better understanding and thus increased control over their responses to stressful events (Kearney et al., 2012). Also, given that those scoring high in neuroticism tend to react more strongly to stressors and past studies have found that mindfulness techniques are beneficial for neurotic individuals (Feltman, Robinson, & Ode, 2009), “mindfulness” based therapies may be another good option for those military personnel scoring high in neuroticism. Resilience did not moderate the relationship between perceived stress and PTSD symptoms or the relationship between perceived stress and AUD symptoms. This stands in contrast to previous results showing that resilience moderated the relationship between stress and psychological strain (Britt, Adler, & Bartone, 1999). The environment of the JTF-GTMO deployment may represent a “strong situation” that decreases the impact of some individual differences on various outcomes (Mischel, 1977). As such, it is possible that the particularly intense operational demands and constraints of the JTF-GTMO deployment reduce the impact of the resilience construct on mental health symptoms.

PTSD and alcohol abuse tend to co-occur with each other, magnifying the negative consequences of these disorders. The current research adds to the literature investigating shared (common) vulnerability factors that may predispose individuals to experience both PTSD and alcohol abuse. Results show that although several explanatory factors are related to both PTSD and alcohol abuse, few relate to both PTSD and alcohol abuse in the same manner. Perceived stress, neuroticism, and psychotherapy stigma all have direct multivariate relationships with PTSD. Further, the positive relationship between perceived stress and PTSD is significantly stronger among those high in neuroticism and psychotherapy stigma. In contrast, the positive relationship between perceived stress and alcohol abuse was only significant among those scoring high in psychotherapy stigma. Neuroticism plays a significant role in the relationship between perceived stress and PTSD, but not perceived stress and AUD. Clinical strategies (e.g., mindful-based therapies) that target neurotic tendencies (e.g., overall feelings of tension and anxiety, anger/irritation) could help individuals better manage similar symptoms that are associated with PTSD (e.g., hypervigilance, easily irritated). Another possibility is to teach those who are high on neuroticism to better cope with these tendencies in order to potentially prevent or mitigate the development of PTSD in cases of extreme/traumatic stress. Our findings show that psychotherapy stigma significantly impacts the relationships between perceived stress and PTSD and between perceived stress and AUD. This is consistent with the literature that shows that those with higher levels of mental health symptomatology perceive higher levels of stigma (Hoge et al., 2004). Thus, strategies to decrease stigma can have extraordinary benefits to those individuals suffering from PTSD symptoms and tendencies toward hazardous drinking. Stigma needs to be addressed at the individual level (e.g., challenging thoughts that seeking mental health care is a sign of weakness) and the military system level (e.g., ensuring that leaders do not punish service members for seeking mental health care). Overall, those who are experiencing PTSD symptoms and tendencies toward alcohol abuse may be especially hesitant to seek mental health care due to psychotherapy stigma. However, if those obstacles can be overcome, treatments that target both PTSD and AUD, such as Seeking Safety, have shown efficacy (Najavits & Hien, 2013).

5.1. Limitations The results of the current study should be interpreted with caution given the limitations inherent in the study design. The generalizability of results is limited given the particular stressors associated with the JTF-GTMO deployment. Personnel deployed to JTF-GTMO are put under intense public scrutiny, have little autonomy in how they carry out their daily jobs (Johnston et al., 2011), and are often put in situations where they must engage in challenging interactions with detainees (Bloche & Marks, 2005). One limitation is that ethnic background was not collected. As such, the representativeness of the sample is difficult to establish. Also, given the sample is predominantly younger, male, Navy personnel, it is possible that these results do not generalize to the broader military. Another limitation is the use of cross-sectional and self-reported data. Because all measures were collected at a single time point, cause-and-effect relationships cannot be established and the direction of relationships is also unclear. For example, it is possible that higher PTSD symptoms result in greater perceived stress. It is also possible that psychotherapy stigma is a consequence of PTSD or AUD symptoms. The current study is unable to determine if psychotherapy stigma influenced participants' decisions to seek out therapy. Although all measures were collected anonymously to reduce bias in responding,

Role of funding sources No specific agency or organization provided funding for this study. No specific agency or organization had any role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors Dr. De La Rosa developed the hypotheses, conducted the statistical analyses, and wrote up the results of the analyses. Dr. Delaney, Dr. Webb-Murphy, and Dr. Johnston assisted in the writing of the introduction and discussion sections. Dr. Johnston selected all assessment measures and collected all data reported here. Conflict of interest All authors declare they have no conflicts of interest. Acknowledgments Elizabeth Vishnyak and Stephanie Raducha provided support for this research.

References Addis, M.E., & Jacobson, N.S. (2000). A closer look at the treatment rationale and homework compliance in cognitive-behavioral therapy for depression. Cognitive Therapy and Research, 24, 313–326. Adler, A.B., Castro, C.A., & McGurk, D. (2009). Time-driven battlemind psychological debriefing: A group-level early intervention in combat. Military Medicine, 174(1), 021–028.

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G.M. De La Rosa et al. / Addictive Behaviors 50 (2015) 128–134

Agaibi, C.E., & Wilson, J.P. (2005). Trauma, PTSD, and resilience a review of the literature. Trauma, Violence & Abuse, 6(3), 195–216. Aiken, L.S., & West, S.G. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: American Psychiatric Association. Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B., & Monteiro, M.G. (2001). AUDIT the alcohol use disorders identification test guidelines for use in primary care. Switzerland: World Health Organization Geneva. Bartone, P.T. (1999). Hardiness protects against war-related stress in Army Reserve forces. Consulting Psychology Journal Practice and Research, 51(2), 72. Besser, A., Neria, Y., & Haynes, M. (2009). Adult attachment, perceived stress, and PTSD among civilians exposed to ongoing terrorist attacks in Southern Israel. Personality and Individual Differences, 47(8), 851–857. Besterman-Dahan, K., Barnett, S., Hickling, E., Elnitsky, C., Lind, J., Skvoretz, J., et al. (2012). Bearing the burden: Deployment stress among Army National Guard chaplains. Journal of Health Care Chaplaincy, 18(3-4), 151–168. Bloche, M.G., & Marks, J.H. (2005). Doctors and interrogators at Guantanamo Bay. New England Journal of Medicine, 353(1), 6–8. Brady, K.T., Back, S.E., & Coffey, S.F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science, 13(5), 206–209. Brailey, K., Vasterling, J.J., Proctor, S.P., Constans, J.I., & Friedman, M.J. (2007). PTSD symptoms, life events, and unit cohesion in US soldiers: Baseline findings from the neurocognition deployment health study. Journal of Traumatic Stress, 20(4), 495–503. Bray, R.M., Fairbank, J.A., & Marsden, M.E. (1999). Stress and substance use among military women and men. The American Journal of Drug and Alcohol Abuse, 25(2), 239–256. Bray, R.M., & Hourani, L.L. (2007). Substance use trends among active duty military personnel: Findings from the United States Department of Defense Health Related Behavior Surveys 1980–2005. Addiction, 102(7), 1092–1101. Bystritsky, A., Wagner, A.W., Russo, J.E., Stein, M.B., Sherbourne, C.D., Craske, M.G., et al. (2005). Assessment of beliefs about psychotropic medication and psychotherapy: Development of a measure for patients with anxiety disorders. General Hospital Psychiatry, 27(5), 313–318. Campbell-Sills, L., Cohan, S.L., & Stein, M.B. (2006). Relationship of resilience to personality, coping, and psychiatric symptoms in young adults. Behaviour Research and Therapy, 44(4), 585–599. Carney, M.A., Armeli, S., Tennen, H., Affleck, G., & O'Neil, T.P. (2000). Positive and negative daily events, perceived stress, and alcohol use: A diary study. Journal of Consulting and Clinical Psychology, 68(5), 788. Casella, L., & Motta, R. W. (1990). Comparison of characteristics of Vietnam Veterans with and without posttraumatic stress disorder. Psychological Reports, 67(2), 595–605. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396. Cooper, M.L., Russell, M., Skinner, J.B., Frone, M.R., & Mudar, P. (1992). Stress and alcohol use: Moderating effects of gender, coping, and alcohol expectancies. Journal of Abnormal Psychology, 101(1), 139. Costa, P.T., & McCrae, R.R. (1992). Revised NEO personality inventory (NEO PI-R) and NEO five-factor inventory (NEO-FFI), Vol. 101, Odessa, FL: Psychological Assessment Resources. Cottler, L.B., Nishith, P., & Compton, W.M. (2001). Gender differences in risk factors for trauma exposure and posttraumatic stress disorder among inner-city drug abusers in and out of treatment. Journal of Comparative Psychiatry, 42, 111–117. De La Rosa, G.M., Webb-Murphy, J., & Johnston, S. (2015). Development of two brief measures of psychological resilience. Philadelphia, PA: Poster presented at the 2015 Society for Industrial and Organizational Psychology Meeting. Dolan, C.A., & Adler, A.B. (2006). Military hardiness as a buffer of psychological health on return from deployment. Military Medicine, 171(2). Emrick, C.D. (1975). A review of psychologically oriented treatment of alcoholism: The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. Journal of Studies on Alcohol and Drugs, 36(01), 88–108. Enns, M.W., Cox, B.J., & Clara, I.P. (2005). Perfectionism and neuroticism: A longitudinal study of specific vulnerability and diathesis-stress models. Cognitive Therapy and Research, 29(4), 463–478. Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA, 252(14), 1905–1907. Feltman, R., Robinson, M.D., & Ode, S. (2009). Mindfulness as a moderator of neuroticism– outcome relations: A self-regulation perspective. Journal of Research in Personality, 43(6), 953–961. Green, B.L., Grace, M.C., Lindy, J.D., Gleser, G.C., & Leonard, A. (1990). Risk factors for PTSD and other diagnoses in a general sample of Vietnam veterans. The American Journal of Psychiatry, 1(47), 729. Haase, L., Thom, N.J., Shukla, A., Davenport, P.W., Simmons, A.N., Paulus, M.P., et al. (2014). Mindfulness-based training attenuates insula response to an aversive interoceptive challenge. Social Cognitive and Affective Neuroscience, 9(4). Hasin, D.S., Stinson, F.S., Ogburn, E., & Grant, B.F. (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results

from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry, 64(7), 830–842. Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13–22. Johnson, D.C., Polusny, M.A., Erbes, C., King, D., King, L., Litz, B., et al. (2008). Development and initial validation of the Response to Stressful Experiences Scale. Military Medicine, 176(2), 161–169. Johnston, S., Webb-Murphy, J., Raducha, S., & Abou, E. (2011, August). Operational stress in detainee operations at Joint Task Force Guantanamo Bay Cuba. Paper presented at the American Psychological Association Annual Conference. D.C.: Washington. Kang, H.K., Natelson, B.H., Mahan, C.M., Lee, K.Y., & Murphy, F.M. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War Veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiology, 157(2), 141–148. Kearney, D.J., McDermott, K., Malte, C., Martinez, M., & Simpson, T.L. (2012). Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample. Journal of Clinical Psychology, 68(1), 101–116. Kessler, R.C., Berglund, P., Delmer, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060. Kulka, R.A., Schlenger, W.E., Fairbank, I.A., Hough, R.L., Jordan, B.K., Marmar, C.R., et al. (1988). Contractual report of findings from the National Vietnam Veterans Readjustment Study. North Carolina: Research Triangle Institute. Kumpfer, K.L. (2002). Factors and processes contributing to resilience. In resilience and development. US: Springer, 179–224. Magill, M., & Ray, L.A. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials. Journal of Studies on Alcohol and Drugs, 70, 516–527. McCauley, J.L., Killeen, T., Gros, D.F., Brady, K.T., & Back, S.E. (2012). Posttraumatic stress disorder and co-occurring substance use disorders: Advances in assessment and treatment. Clinical Psychology: Science and Practice, 19(3), 283–304. Mennis, J., & Mason, M.J. (2012). Social and geographic contexts of adolescent substance use: The moderating effects of age and gender. Social Networks, 34(1), 150–157. Miller, M.W., Vogt, D.S., Mozley, S.L., Kaloupek, D.G., & Keane, T.M. (2006). PTSD and substance-related problems: The mediating roles of disconstraint and negative emotionality. Journal of Abnormal Psychology, 115(2), 369. Mischel, W. (1977). The interaction of person and situation. In D. Magnusson, & N.S. Endler (Eds.), Personality at the crossroads: Current issues in interactional psychology (pp. 333–352). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Najavits, L.M., & Hien, D. (2013). Helping vulnerable populations: A comprehensive review of the treatment outcome literature on substance use disorder and PTSD. Journal of Clinical Psychology, 69(5), 433–479. O'Farrell, T.J., & Fals-Stewart, W. (2000). Behavioral couples therapy for alcoholism and drug abuse. Journal of Substance Abuse Treatment, 18(1), 51–54. Ramchand, R., Schell, T.L., Karney, B.R., Osilla, K.C., Burns, R.M., & Caldarone, L.B. (2010). Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal of Traumatic Stress, 23(1), 59–68. Reich, J.H. (1990). Personality disorders and posttraumatic stress disorder. In M.E. Wolf, & A.D. Mosnaim (Eds.), Posttraumatic stress disorder: Etiology, phenomenology, and treatment (pp. 65–79). Washington: American Psychiatric Press. Sherman, J.J. (1998). Effects of psychotherapeutic treatments for PTSD: A meta‐analysis of controlled clinical trials. Journal of Traumatic Stress, 11(3), 413–435. Solomon, Z., Mikulincer, M., & Hobfoll, S.E. (1987). Objective versus subjective measurement of stress and social support: Combat-related reactions. Journal of Consulting and Clinical Psychology, 55(4), 577. Tanielian, T., & Jaycox, L. (Eds.). (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation. Ten Have, M., de Graaf, R., Ormel, J., Vilagut, G., Kovess, V., Alonso, J., et al. (2010). Are attitudes towards mental health help-seeking associated with service use? Results from the European Study of Epidemiology of Mental Disorders. Social Psychiatry and Psychiatric Epidemiology, 45(2), 153–163. Tomaka, J., Morales‐Monks, S., & Shamaley, A.G. (2012). Stress and coping mediate relationships between contingent and global self‐esteem and alcohol‐related problems among college drinkers. Stress and Health, 29(3), 205–213. Weathers, F.W., Litz, B.T., Herman, D.S., Huska, J.A., & Keane, T.M. (1993, October). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. San Antonio, TX: Paper presented at the meeting of the International Society for Traumatic Stress Studies.