Klaudia Mamełka, Ewa Wojtynkiewicz, Michał Danek, Karolina Głogowska, Maciej Michalak The Relationship Between PTSD and CPTSD Symptoms and Alcohol Use in Clinical and Non-clinical Samples

Introduction

According to the National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023), in the United States, 84.9% of individuals over the age of 18 had consumed alcohol at least once in their lifetime, 67.1% in the past year, and 51.6% in the past month. In Europe, 60% of the population over the age of 15 reported alcohol consumption in the last 12 months, with 8.4% drinking daily, 28.8% in the past week, and 22.8% in the past month (WHO, 2021). In 2023, the prevalence of alcohol use disorder (AUD) in the U.S. adult population was 10.9%, including 13.2% among men and 8.7% among women. Additionally, 23.5% of respondents reported binge drinking episodes in the past month (SAMHSA, 2023). Only 7.8% of individuals who met the criteria for AUD in the past year sought treatment (SAMHSA, 2023). These statistics highlight how widespread and problematic alcohol use is.

The literature has extensively examined both biological and psychological determinants, as well as mechanisms, of AUD development (Cierpiałkowska & Chodkiewicz, 2020; Koob & Volkow, 2016; Le Berrei et al., 2017; Litten et al., 2015; Zahr & Pfefferbaum, 2017). Research indicates that AUD frequently co-occurs with other psychiatric disorders, and various theoretical models have been proposed to explain this relationship. For the purposes of this article, one model is particularly relevant – the view that AUD develops as a consequence of earlier psychopathological difficulties (Verheul & van den Brink, 2005). This perspective is consistent with the widely documented self-medication hypothesis (Khantzian, 2018), which posits that psychoactive substances are used to alleviate distress arising from pre-existing psychiatric disorders, thereby contributing to the development of AUD (Haller & Chassin, 2014; Khantzian, 2018; Luciano et al., 2022; Verheul & van den Brink, 2005).

One of the most common psychiatric disorders among individuals with AUD is post-traumatic stress disorder (PTSD), with prevalence estimates ranging from 10% to 66% (Castillo‐Carniglia et al., 2019; Debell et al., 2014; Kingston et al., 2017; Whiteford et al., 2023; Norman et al., 2018; Driessen et al., 2008). In contrast, lifetime PTSD prevalence in the general population ranges from 1% to 14% (and up to 18.8% in Poland; Rzeszutek et al., 2023), underscoring the disproportionately high prevalence of PTSD among individuals with AUD. Research shows that individuals with both AUD and PTSD are at greater risk of additional psychiatric and physical health problems (Bowe & Rosenheck, 2015), more severe AUD (Whiteford et al., 2023), and more serious emotional and psychosocial difficulties (Cohen & Hien, 2006; Drapkin et al., 2011). Furthermore, individuals diagnosed with both PTSD and AUD are over three times more likely to attempt suicide compared to those with PTSD alone (Cohen & Hien, 2006; Drapkin et al., 2011). They also more frequently experience depression and anxiety, use psychiatric treatment, and report poorer cognitive-emotional functioning and lower quality of life (Cohen & Hien, 2006; Drapkin et al., 2011).

Dell’Aquila and Berle (2023) emphasize that relational forms of trauma—especially those occurring repeatedly—substantially increase the likelihood of developing PTSD and, subsequently, AUD. Numerous studies demonstrate a strong link between childhood traumatic experiences and AUD in adulthood (Holl et al., 2017; Wardell et al., 2016), noting that such experiences often precede the onset of AUD (Anda et al., 2006; Cross et al., 2015; Dom et al., 2007; Pilowsky et al., 2009; Schindler, 2019; Ullman et al., 2013; Walsh et al., 2014). Research indicates that childhood experiences of sexual, physical, and emotional abuse are associated with earlier initiation of alcohol use, heavier consumption, binge drinking, and the subsequent development of AUD (Dutcher et al., 2017; Eames et al., 2014; Lotzin et al., 2016). Among adults seeking treatment, childhood abuse and neglect have been identified as significant risk factors for more severe AUD symptoms (Potthast et al., 2014), destructive drinking patterns, and poorer treatment outcomes (Lotzin et al., 2016; MacMillan et al., 2001; Greenfield et al., 2002). Huang et al. (2012) found that 55.1% of adults with AUD (47% of men and 72.6% of women) reported childhood trauma, with 21.4% reporting emotional abuse, 31.1% physical abuse, 24% sexual abuse, 20.4% emotional neglect, and 19.9% physical neglect. Due to this high comorbidity of AUD with PTSD and traumatic experiences, PTSD has been identified as a major therapeutic challenge in addiction treatment (Gielen et al., 2014; Mefodeva et al., 2023; Roberts et al., 2023).

Given the high prevalence of relational trauma among individuals with AUD, researchers have recently turned their attention to the occurrence of complex post-traumatic stress disorder (CPTSD) in this population. CPTSD, which encompasses a broader range of psychological difficulties, may better capture the psychopathological consequences of prolonged traumatic experiences, making it particularly relevant for addiction treatment (Whiteford et al., 2023). According to ICD-11, a CPTSD diagnosis requires meeting all PTSD criteria (re-experiencing, avoidance, and sense of current threat) along with additional symptoms referred to as disturbances in self-organization (DSO). DSO symptoms include persistent difficulties in emotion regulation, negative self-concept, and relational disturbances, all of which result in significant functional impairment (Whiteford et al., 2023). To date, only a handful of studies have examined links between CPTSD and AUD. Their findings suggest that CPTSD symptoms may influence the severity of alcohol use (Whiteford et al., 2023). Moreover, DSO symptoms appear to have a stronger impact on alcohol use severity than PTSD symptoms alone (Whiteford et al., 2023). By contrast, Rossi et al. (2023) reported a stronger association of AUD with PTSD than with CPTSD.

As noted, attempts to explain the high co-occurrence of childhood trauma, PTSD, and AUD often reference the self-medication model (Berenz et al., 2016; Dutcher et al., 2017; Ertl et al., 2016). While other hypotheses have been proposed–such as the high-risk hypothesis (alcohol use problems increasing the risk of trauma exposure), the susceptibility hypothesis (alcohol use problems themselves increasing vulnerability), and the shared vulnerability hypothesis (a common factor influencing both PTSD and AUD) – the strongest evidence supports the self-medication hypothesis (Haller & Chassin, 2014). This framework can also help explain CPTSD–AUD relationships, assuming that childhood maltreatment, as a relational trauma characteristic of CPTSD, may lead individuals lacking adaptive emotion regulation strategies to use alcohol as a means of avoiding or reducing negative emotional states (Khantzian, 1997; Wolff et al., 2016).

In light of previous findings, it is essential to further deepen and integrate our understanding of PTSD–AUD and CPTSD–AUD relationships. Such analyses not only clarify the psychopathological mechanisms underlying comorbidity but also provide a basis for coherent theoretical models of alcohol problems in trauma-exposed individuals. Furthermore, they support the development of integrated treatment models for AUD that address co-occurring PTSD or CPTSD. Recent reviews and meta-analyses indicate that one of the most effective strategies for treating substance use disorders (SUD) and PTSD is integrated, trauma-focused therapy (e.g., Concurrent Treatment of PTSD and SUD Using Prolonged Exposure, COPE), supplemented with pharmacotherapy for AUD. Although treatment outcomes are moderate and dropout rates remain high, integrated approaches yield better prognoses than treating these conditions separately (Hien et al., 2024; Roberts et al., 2022).

Method

Aim of the Study

The research presented in this article included both a non-clinical group (individuals from the general population) and a clinical group (patients with AUD). The aims were to examine the prevalence of PTSD and CPTSD in both groups and to determine whether prevalence differed between them. It was hypothesized that prevalence would be significantly higher in the clinical group. Additionally, the study aimed to assess whether PTSD and CPTSD symptoms and their dimensions were associated with the severity of alcohol use in the non-clinical group. It was expected that higher levels of PTSD and CPTSD symptoms would be linked to greater alcohol use in individuals without AUD, in both women and men.

Procedure

The study was conducted using paper-and-pencil questionnaires. A total of 552 adults participated: 369 individuals from the non-clinical group, recruited through the snowball sampling method, and 183 patients with AUD recruited from inpatient and day-treatment addiction facilities in the Kuyavian-Pomeranian Voivodeship. For the clinical group, ethical approval was obtained from the Bioethics Committee of the Nicolaus Copernicus University Collegium Medicum in Toruń. Participation was voluntary and anonymous in both groups. All participants were informed about the study objectives and provided written informed consent.

Material

The non-clinical group consisted of 369 participants, including 266 women and 103 men, with a mean age of 38.61 years (SD = 14.79). The clinical group comprised 183 participants, 39 women and 144 men, with a mean age of 44.11 years (SD = 12.10). Detailed characteristics regarding education, marital status, and place of residence are presented in Table 1.

Methods

To assess PTSD and CPTSD symptoms, the Polish adaptation (Draczyńska et al., 2025) of the International Trauma Questionnaire (ITQ) by Cloitre et al. (2018) was used. The scale was developed based on the ICD-11 diagnostic criteria for PTSD and CPTSD. Responses are provided on a 5-point Likert scale ranging from not at all (0) to extremely (4), with a score of 2 (moderately) considered an indicator of symptom presence. The ITQ includes 12 items measuring core PTSD and CPTSD symptoms (Cloitre et al., 2018; Draczyńska et al., 2025). For PTSD, the questionnaire covers: (1) re-experiencing (Re), (2) avoidance (Av), and (3) sense of current threat (TH), as well as functional impairment criteria. CPTSD symptoms measured by the ITQ include disturbances in self-organization (DSO): (1) affective dysregulation (AD), (2) negative self-concept (NSC), and (3) disturbances in relationships (DR), along with additional functional impairment criteria related to relational, occupational, and other important areas (DSOFI) (Draczyńska et al., 2022).

Reliability analysis showed that in this study, Cronbach’s alpha was 0.92 for the PTSD subscale and 0.91 for the CPTSD subscale.

To measure the severity of alcohol use, the Problem Drinking Scale (PDS; Kotowska et al., 2022) was employed. This instrument, based on the DSM-5 conceptualization of alcohol use disorder, consists of 22 items rated on a 0–2 scale: 0 – absent/rarely, 1 – often, 2 – almost always. For each of the 11 DSM-5 diagnostic criteria, scores range from 0 to 4 points. The scale enables the approximate assessment of current alcohol-related problems in four domains: impaired control of drinking behavior, impaired social functioning, risky substance use, and pharmacological aspects (Kotowska et al., 2022). In this study, the total score was used. Reliability analysis indicated Cronbach’s alpha = 0.90.

Data Analysis Methods

Data were analyzed using Statistica 13.4. Results with p < 0.05 were considered statistically significant. Group differences in PTSD and CPTSD prevalence were tested with chi-square tests of independence. Associations were examined using Pearson’s correlation coefficient.

Results

First, the prevalence of PTSD and CPTSD was examined in the non-clinical group. The analysis showed that just over 18% of participants met the criteria for probable PTSD, while about 14% met the criteria for probable CPTSD. Without these probable diagnoses, approximately 67.5% of participants were symptom-free. Detailed prevalence data by gender are presented in Table 2.

In the clinical group, analyses showed that nearly 34% of patients met the criteria for PTSD, while about 22% met the criteria for CPTSD. When gender was considered, almost 95% of women in the clinical group met the criteria for either PTSD or CPTSD. This percentage was significantly higher than among men, 45% of whom met the criteria for one of the disorders. Detailed data are presented in Table 3.

Analyses revealed significant differences in PTSD and CPTSD prevalence between the clinical and non-clinical groups. In the clinical group, 33.9% met the criteria for PTSD compared to 18.2% in the non-clinical group. This difference was statistically significant (χ²(1, N = 552) = 16.02, p < 0.001, V = 0.17). CPTSD prevalence was also higher in the clinical group (21.9%) compared to the non-clinical group (14.4%), and this difference was statistically significant (χ²(1, N = 552) = 4.38, p = 0.036, V = 0.09).

Additionally, PTSD and CPTSD prevalence were compared by gender in the AUD group. Results indicated that women in the clinical group were significantly more likely to meet the criteria for both disorders: PTSD – 56.4% of women vs. 27.8% of men (χ²(1, N = 183) = 9.99, p < 0.001, V = 0.23), and CPTSD – 38.5% of women vs. 17.4% of men (χ²(1, N = 183) = 6.81, p = 0.009, V = 0.19).

In summary, the results suggest that PTSD and CPTSD occur significantly more often in the clinical group than in the non-clinical group, with gender differences particularly evident among clinical participants–especially the higher prevalence in women.

Another aim of the study was to examine whether PTSD and CPTSD symptoms and their dimensions were associated with alcohol use in the non-clinical group. Analyses showed statistically significant associations between PTSD and CPTSD symptoms and alcohol use for both women and men.

Among women, positive and strong correlations were observed between all PTSD dimensions and alcohol use, as well as positive correlations of varying strength (strong, moderate, or weak) between all CPTSD dimensions and alcohol use. As hypothesized, greater severity of PTSD or CPTSD symptoms was associated with higher alcohol use in women.

Among men, positive and strong correlations were observed between almost all PTSD dimensions and alcohol use, with the exception of the avoidance dimension, which showed no significant association. For CPTSD, positive correlations of varying strength were also observed between most dimensions and alcohol use, except for the disturbances in relationships dimension, which showed no significant association in men. Detailed correlation results are presented in Table 4.

*p < 0.05, **p < 0.01, *** p < 0.001

Discussion

This study aimed to examine the prevalence of PTSD and CPTSD in individuals with AUD and in a non-clinical group from the general population, as well as to test whether prevalence differed between these groups. As hypothesized, significant differences were observed.

In the non-clinical sample, PTSD prevalence was approximately 18% and CPTSD prevalence was 14%. These results are consistent with previous epidemiological findings. Globally, PTSD prevalence in the general population is estimated at 3.9% (Koenen et al., 2017). In the United States, lifetime prevalence is 6.1% and 12-month prevalence is 3.6%, with higher rates in women (5.2%) than in men (1.8%) (National Institute of Mental Health [NIMH], 2023). In Poland, Rzeszutek et al. (2023) reported a probable PTSD prevalence of 18.8%, closely aligning with our results. With regard to CPTSD, a recent meta-analysis by Huynh et al. (2025) estimated global prevalence at 6.2%, with large variation across trauma-exposed populations–highest in clinical samples (44.7%), victims of domestic violence or sexual abuse (40%), and military populations (36.4%), and lowest among emergency service workers (7.4%). The CPTSD prevalence in our non-clinical group (14%) is consistent with findings by Rzeszutek et al. (2024), who reported 11% prevalence in Poland.

In the clinical AUD group, probable PTSD prevalence was nearly 34%, including 56.5% of women and about 28% of men. These values fall within the range reported in earlier studies (10%–66%; Ralevski et al., 2013; Miturska, 2011). Consistent with prior research, PTSD symptoms were more common in women with AUD than in men (Miturska, 2011; Saraiya et al., 2022). Probable CPTSD prevalence in the clinical group was about 22%, including 38.5% of women and 17.5% of men. Importantly, almost 95% of women in the clinical group met criteria for either PTSD or CPTSD, compared to 45% of men. These striking gender differences support the notion of gender-specific developmental pathways linking PTSD, coping strategies, and alcohol use (Sonne et al., 2003), and suggest that in women, AUD may often be secondary to pre-existing psychopathology.

Our analyses confirmed significant differences in PTSD and CPTSD prevalence between the clinical and non-clinical groups, with higher prevalence in the clinical sample. These results underscore the diagnostic relevance of PTSD and CPTSD in the context of AUD. However, diagnosing these conditions remains challenging, as their symptoms often overlap with those of depression, anxiety, or substance use disorders (Cloitre et al., 2013; Kazlauskas et al., 2022). For example, chronic difficulties in emotion regulation or avoidance of stress may be misattributed to alcohol misuse rather than recognized as core CPTSD symptoms. Such diagnostic ambiguity can have serious consequences, leading to a narrow treatment focus on alcohol reduction while neglecting trauma-related distress (Rossi et al., 2023). Accurate differentiation of PTSD and CPTSD in patients with AUD may therefore be crucial for effective treatment planning. Integrated treatment models, such as COPE (which combines prolonged exposure with relapse-prevention elements; Killeen et al., 2011; Back et al., 2019) or Seeking Safety (Najavits, 2009), offer promising approaches. However, evidence for their effectiveness remains mixed (Hien et al., 2024; Roberts et al., 2022), indicating the need for further refinement and development of integrated interventions.

Another aim of this study was to examine whether PTSD and CPTSD symptom severity are associated with alcohol use in individuals without AUD. Our findings confirmed that higher levels of both PTSD and CPTSD symptoms were significantly related to greater alcohol use. This supports the self-medication hypothesis (Swendsen et al., 2010; Rossi et al., 2023), which proposes that alcohol is used to regulate trauma-related emotions by reducing awareness of distress (Ball, 2007; Sakulsriprasert et al., 2023). While such avoidance may temporarily alleviate suffering, it increases the risk of developing problematic drinking patterns.

Early recognition of PTSD and CPTSD symptoms in individuals without AUD is therefore of particular importance. Trauma symptoms may escalate alcohol use, impair adaptation, and increase relapse risk (Anda et al., 2006; Cross et al., 2015; Dom et al., 2007; Pilowsky et al., 2009). Comprehensive assessment not only clarifies the sources of distress but also enables targeted support, even before a formal AUD diagnosis is established (Kessler et al., 1995; Cloitre et al., 2013; Najavits, 2009).

This study has several limitations. In the clinical group, the number of women was relatively small, reducing the representativeness of results for women with AUD. In the non-clinical group, most participants had secondary or higher education, with vocationally educated individuals underrepresented. Additionally, the cross-sectional design precludes causal inferences, allowing only conclusions about co-occurrence.

Despite these limitations, the findings have practical implications. They highlight the necessity of systematically assessing PTSD and CPTSD in patients treated for AUD, as well as screening for AUD (including subclinical levels) in individuals presenting with trauma-related symptoms.

Conclusions

This study demonstrates that PTSD and CPTSD are strongly associated with alcohol use. Alcohol may serve as a maladaptive emotion regulation strategy in trauma-exposed individuals, increasing the risk of AUD. These findings emphasize the importance of incorporating trauma assessment into both diagnostic and therapeutic processes. Failure to recognize trauma’s role in shaping substance-use behaviors may reduce the effectiveness of interventions that focus exclusively on alcohol reduction.

Funding

The task was co-financed from the resources of the Gambling Problems Resolution Fund, commissioned by the National Centre for the Prevention of Addictions.

References