Abstract

Aims

The objective of the current study was to describe and analyse associations between childhood emotional abuse, severity of depressive symptoms, and analgesic expectations of drinking in individuals with alcohol use disorder (AUD).

Methods

A total of 240 individuals aged 43.85 ± 11.0 with severe AUD entering an inpatient, abstinence-based, and drug-free treatment program were assessed. The data on AUD severity, depressive symptoms, expectations towards the analgesic effects of alcohol and childhood emotional trauma was collected using questionnaire measures. The PROCESS SPSS macro for serial mediation with bootstrapping was used to test whether current severity of depressive symptoms and expectations towards analgesic effects of alcohol use serially mediated the association between childhood emotional abuse on AUD symptom severity.

Results

There was evidence for two simple mediated effects, whereby the severity of depressive symptoms mediated the association between childhood emotional abuse on AUD symptom severity, and expectations towards analgesic effects of alcohol mediated the association between childhood emotional abuse on AUD symptom severity. There was also evidence to support serial mediation whereby both severity of depressive symptoms and expectations towards analgesic effects of alcohol mediated the association between childhood emotional abuse on AUD symptom severity.

Conclusions

It might be clinically relevant to address experiences of childhood emotional trauma, as well as individual expectations of analgesic effects of alcohol, in AUD treatment programs.

Introduction

Adverse childhood events, especially childhood maltreatment, are considered critical factors for developing psychiatric disorders. Exposure to maltreatment in childhood may predict severity of numerous psychiatric disorders, among them alcohol use disorder (AUD) in adulthood (Win et al. 2021). There is a considerable number of studies that address the role of childhood maltreatment (defined here as physical abuse and neglect, emotional abuse and neglect, and sexual abuse) in the development of AUD. A suggested mechanism linking childhood maltreatment with AUD are coping motives. That is, individuals who experienced childhood maltreatment are not only more likely to experience intense negative emotions (e.g. anxiety, depressed mood), but they may be more likely to use alcohol as a way to cope with these rather than manage them in a more constructive manner (Shin et al. 2020a). Although all forms of childhood maltreatment may be associated with AUD, emotional abuse was found to be an independent predictor of earlier onset (Schuckher et al. 2018) and higher AUD severity compared to other forms of maltreatment (Schwandt et al. 2013). For example, one study conducted using the National Epidemiologic Survey on Alcohol and Related Conditions dataset shows that individuals with a history of childhood maltreatment initiated alcohol drinking one year earlier than those without a history of childhood maltreatment. It was also found that among women with AUD and a history of childhood maltreatment, time between drinking initiation and AUD was significantly shorter compared to women without a history of childhood maltreatment (Oberleitner et al. 2015). Moreover, men with AUD and a history of childhood trauma endorsed higher drinking severity compared to men without a history of maltreatment (Eames et al. 2014). Another study found that individuals with AUD and a history of childhood maltreatment tended to have worse treatment outcomes (Borgert et al. 2023), as well as poorer quality of life (Sassoon et al. 2023), compared with those with AUD without a history of childhood maltreatment.

Recently, there has been an increase in studies demonstrating an association between childhood maltreatment and depressive symptoms. Some work indicates that childhood maltreatment is linked to higher risk and severity of depressive symptoms (Kuzminskaite et al. 2021; Song et al. 2022). Furthermore, depressive symptoms were found to mediate the association between childhood maltreatment and life satisfaction (Xiang et al. 2021), as well as between childhood maltreatment and problem drinking in adulthood (Shin et al. 2020b). A prospective study on a large group of Australian mother and child pairs found that 4.5% of participants reported a history of childhood maltreatment, with emotional abuse being the most common, and that childhood maltreatment had a strong association with depressive symptoms (Kisely et al. 2018). In a recent meta-analysis, although each type of childhood maltreatment was associated with greater depressive symptoms, emotional abuse demonstrated the strongest association (Humphreys et al. 2020). Researchers propose that a potential mechanism linking emotional abuse and depressive symptoms may be low self-compassion (Wu et al. 2018), high emotion dysregulation (Christ et al. 2019), high interpersonal problems (Christ et al. 2019), or high deviant peer affiliation (Li et al. 2022).

As noted, alcohol is widely used as a coping strategy against emotional pain (i.e. negative affect); yet, recent studies indicate that alcohol has purely analgesic properties that mainly act to relieve the intensity of pain. This may explain prior work demonstrating significantly higher levels of alcohol use and AUD in individuals experiencing chronic pain (Thompson et al. 2017). It was also shown that more than 50% of individuals seeking treatment for AUD may suffer from chronic recurrent pain (Boissoneault et al. 2019). In fact, the amount of alcohol one consumes may be associated with pain severity, since reductions in alcohol consumption may reduce acute pain severity (Edwards et al. 2020).

Importantly, physical pain constitutes both somatic and mental suffering (Peters 2015). Studies show that >50% of chronic pain patients also manifest clinical symptoms of depression (Bair et al. 2003). The association between pain and negative affect is bidirectional: pain aggravates concurrent negative emotions, which then aggravates the experience of pain (Wiech and Tracey 2009). Individuals high in negative affect were found to report significantly higher pain sensitivity (Wunsch et al. 2003), lower pain thresholds (Meagher et al. 2001), and also greater activation in brain regions that process emotions (the amygdala and ventrolateral prefrontal cortex; Adler-Neal et al. 2019). Taken together, sensory and affective components simultaneously contribute to the multifaceted experience of pain. It has been shown that pain can be experienced in the absence of nociception (i.e. with no sensory stimulation of nociceptive afferents), and can be derived solely from emotional sources (Navratilova and Porreca 2014). Importantly, alcohol may be used to reduce both somatic and emotional components of pain (Edwards et al. 2020), even when these cannot be easily distinguished from each other by an individual. Therefore, there is a clear rationale to assess analgesic effects of alcohol in the context of its relieving effect on negative affect.

Alcohol-related outcome expectancies are often shaped through personal experiences with alcohol use, or more indirectly through social learning early in life. Alcohol expectations in early adolescence (before alcohol drinking initiation) was associated with subsequent alcohol intoxication, frequency of alcohol intoxications (Cranford et al. 2010) and onset of problem drinking (Cooper et al. 1988). Expectations that alcohol use would reduce pain (alcohol analgesia) was linked with greater alcohol use in a group of individuals with and without chronic pain (LaRowe et al. 2022). Higher pain relief expectancies after alcohol use might be associated with higher ratings of pain relief (Alexander et al. 2024). Still, only a few studies have examined alcohol analgesia expectancies among individuals with an AUD. One exception is the experimental study conducted by Cutter et al. (1976), which found that patients with an AUD reported experiencing less pain than healthy controls on a cold pressor test following the use of alcohol.

Patients with chronic pain are more likely to report exposure to childhood maltreatment than healthy controls. Namely, there is growing evidence that individuals with a history of childhood maltreatment experienced greater pain symptoms, increased pain severity, and more pain-related conditions compared with those without a maltreatment history. In addition, they may be twice as likely to experience chronic pain in adulthood. For example, patients with functional abdominal pain were 8.2 times more likely to report childhood maltreatment compared to a non-clinical comparison group (Davis et al. 2005; Cay et al. 2022; Tidmarsh et al. 2022).

Despite the recent elevated interest in the prominence of pain among individuals with AUD, little work has been done to study the association between childhood maltreatment and pain in this population. A key exception is a study demonstrating that among a group of adults with AUD and a history of childhood sexual abuse, pain ailments were more severe than those without a history of childhood maltreatment (Jakubczyk et al. 2015). Moreover, it is possible that the association between emotional abuse and pain tolerance is mediated by negative affect (Zaorska et al. 2020). However, we are not aware of any study that has investigated the role of childhood maltreatment with analgesic expectations of drinking in the context of depressive symptoms and AUD severity.

The objective of the current study was to describe and analyse associations between childhood maltreatment, severity of depressive symptoms, and analgesic expectations of drinking in individuals with AUD. For the purpose of this study, the unique role of emotional abuse was considered given previous studies suggesting that this form of childhood maltreatment is a strong predictor of earlier onset (Schuckher et al. 2018) and higher severity of AUD (Schwandt et al. 2013). Moreover, prior work has consistently demonstrated that emotional abuse is more strongly related to negative affect than other forms of childhood maltreatment (Martins et al. 2014; Nelson et al. 2017).

We hypothesized that among adults with AUD, greater severity of childhood emotional abuse would be associated with higher severity of depressive symptoms, higher expectations towards analgesic effects of alcohol, and higher severity of AUD symptoms. Furthermore, we hypothesized that severity of depressive symptoms and expectations toward analgesic effects of alcohol would mediate the association between childhood emotional abuse and severity of AUD symptoms.

Material and methods

The sample was derived from an ongoing study conducted at the Medical University of Warsaw, Poland, investigating the behavioral and emotional functioning of individuals diagnosed with AUD. More specifically, 240 individuals aged 43.85 ± 11.0 with severe AUD (but without acute withdrawal symptoms) entering an inpatient, abstinence-based, drug-free treatment program were assessed. The treatment was primarily comprised of cognitive-behavioral therapy and psychoeducation. AUD diagnosis for each patient was derived from the International Classification of Diseases and Related Health Problems 10th Revision (WHO 1992) upon admission to the treatment facility, and was later confirmed through the MINI International Neuropsychiatric Interview (Sheehan et al. 1998). Individuals meeting the following criteria were excluded: a clinically significant cognitive deficit (<25 on the Mini-Mental State Examination) (Folstein et al. 1975), a history of psychosis, co-occurring current psychiatric disorders requiring medication, current use of analgesics, and co-occurrence of substance use/dependence other than nicotine. Moreover, patients recruited for the current study did not experience acute alcohol withdrawal symptoms, as these were a contraindication for admission to the treatment facility. Research procedures were performed during the first two weeks following treatment admission. The study questionnaires were all assessed within the same study visit. However, given the high number of assessments, participants were given 3 days to complete and return the study questionnaires to research staff to limit participant fatigue. Given the overrepresentation of men in substance use treatment programs in Poland, a large portion of the sample comprised White men (85.2%).

The Bioethics Committee at the Medical University of Warsaw approved this study

Measures

AUD severity was evaluated using the Michigan Alcoholism Screening Test (Selzer et al. 1975), which is a self-administered scale. Although originally designed as a diagnostic screening tool, it correlates strongly with the Alcohol Dependence Scale (r = .79), a measure of problem severity (Ross et al. 1990). Higher scores indicate greater severity. A validated Polish translation was used in this study (Falicki et al. 1986; Habrat 1988).

Depressive symptom severity was evaluated with the Beck Depression Inventory (BDI; Beck 1996), which is a 21-item self-report inventory assessing symptoms of depression during the last 2 weeks on three-point Likert scale. For the purpose of this study, the validated Polish version of the questionnaire was used (Zawadzki et al. 2009), which showed good reliability in the Polish population (Cronbach’s alpha = .92).

Expectations towards the analgesic effects of alcohol were assessed with the following item: ‘Do you believe that alcohol is an effective analgesic?’ (which in Polish specifically refers to physical pain) with answers rated on five-point Likert scale ranging from 1 – ‘absolutely no’ to 5 – ‘absolutely yes’.

The Polish version of a short form of the Childhood Trauma Questionnaire (CTQ-SF) was used to assess childhood maltreatment. The CTQ-SF contains 28 items that ask about experiences during childhood and adolescence. Items are rated on a 5-point Likert-type scale ranging from 1 = ‘never true’ to 5 =‘very often true.’ The CTQ-SF has five factors—physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect—that have been empirically derived (Bernstein et al. 1994; Bernstein et al. 1997). The CTQemo (emotional abuse) subscale contains 5 items, for example ‘I thought that my parents wished I had never been born’. As explained earlier, for the purpose of this study only scores from the CTQemo subscale were included in analysis.

Data analysis

Descriptive statistics were calculated as arithmetic means and standard deviations for parametric variables. For non-parametric variables, data are presented as median and quartiles. Correlations among the study variable were evaluated using Pearson correlation coefficient.

Missing values for any of the individual items for the variables included in the mediation model were assigned the mean score of the remaining items in the scale. If more than a single item was missing, the participant was excluded. From the original sample of 240 individuals, 31 were not included in the mediation analysis. These individuals did not differ from the 209 participants included in the final mediation model on sociodemographic variables (i.e. age, education, biological sex).

Serial mediation model

The PROCESS SPSS macro for serial mediation with bootstrapping (5000 resamples with replacement) was used to test whether current severity of depressive symptoms and expectations towards analgesic effects of alcohol use serially mediated the association between childhood emotional abuse on AUD symptom severity (Hayes 2013). Severity of depressive symptoms was entered into the model first. Biological sex and age were included as covariates in the model. The alpha for all the reported P-values was .05.

Bootstrap estimation of effects and confidence intervals is an effective way to address two (normality, homoscedasticity) out of the four (normality, homoscedasticity, linearity, and independence) OLS assumption requirements. Accordingly, sensitivity analyses using the bootstrap method was compared to estimations from the more traditional method (based on formulas taking into account standard deviations calculated from distributions of variables). All effects, confidence intervals, and hence, statistical significance were the same across approaches and discrepancies were negligible in magnitude. Given that estimates across models held firmly, for brevity, we only report estimates based on formulas taking into account standard deviations calculated from distributions of variables.

Results

The descriptive statistics of 209 individuals included in the final model are presented in

Table 1. Bivariate correlations between the primary study variables are presented in Table 2.

Table 1

Descriptive statistics of the individuals with alcohol use disorder (N = 209)

Mean or medianStandard deviation or quartiles
Alcohol use severitya36.889.82
Emotional abuseb20–5
Depression severityc1710.5–23
Age43.7910.89
Years of education11.993.88
Biological sex (male/female; n)175/34-
Mean or medianStandard deviation or quartiles
Alcohol use severitya36.889.82
Emotional abuseb20–5
Depression severityc1710.5–23
Age43.7910.89
Years of education11.993.88
Biological sex (male/female; n)175/34-

Data are presented as arithmetic means and standard deviations for parametric variables

For non-parametric variables, data are presented as median and quartiles (25; 75).

aEvaluated using the Michigan Alcoholism Screening Test

bEmotional abuse subscale from Childhood Trauma Questionnaire

cEvaluated using the Beck Depression Inventory

Table 1

Descriptive statistics of the individuals with alcohol use disorder (N = 209)

Mean or medianStandard deviation or quartiles
Alcohol use severitya36.889.82
Emotional abuseb20–5
Depression severityc1710.5–23
Age43.7910.89
Years of education11.993.88
Biological sex (male/female; n)175/34-
Mean or medianStandard deviation or quartiles
Alcohol use severitya36.889.82
Emotional abuseb20–5
Depression severityc1710.5–23
Age43.7910.89
Years of education11.993.88
Biological sex (male/female; n)175/34-

Data are presented as arithmetic means and standard deviations for parametric variables

For non-parametric variables, data are presented as median and quartiles (25; 75).

aEvaluated using the Michigan Alcoholism Screening Test

bEmotional abuse subscale from Childhood Trauma Questionnaire

cEvaluated using the Beck Depression Inventory

Table 2

Correlations between the variables included in the mediation model

Analgesic effects of alcoholaAlcohol use severityEmotional abuseDepression severity
Alcohol use severitybr0.28
P<.001
Emotional abusecr0.210.28
P0.002<.001
Depression severitydr0.230.240.31
P<.001<.001<.001
Ager−.08−0.23−0.26−0.12
P0.28<.001<.0010.10
Analgesic effects of alcoholaAlcohol use severityEmotional abuseDepression severity
Alcohol use severitybr0.28
P<.001
Emotional abusecr0.210.28
P0.002<.001
Depression severitydr0.230.240.31
P<.001<.001<.001
Ager−.08−0.23−0.26−0.12
P0.28<.001<.0010.10

r values are the Pearson correlation coefficients

aExpectations towards the analgesic effects of alcohol

bEvaluated using the Michigan Alcoholism Screening Test

cEmotional abuse subscale from Childhood Trauma Questionnaire

dEvaluated using the Beck Depression Inventory

Table 2

Correlations between the variables included in the mediation model

Analgesic effects of alcoholaAlcohol use severityEmotional abuseDepression severity
Alcohol use severitybr0.28
P<.001
Emotional abusecr0.210.28
P0.002<.001
Depression severitydr0.230.240.31
P<.001<.001<.001
Ager−.08−0.23−0.26−0.12
P0.28<.001<.0010.10
Analgesic effects of alcoholaAlcohol use severityEmotional abuseDepression severity
Alcohol use severitybr0.28
P<.001
Emotional abusecr0.210.28
P0.002<.001
Depression severitydr0.230.240.31
P<.001<.001<.001
Ager−.08−0.23−0.26−0.12
P0.28<.001<.0010.10

r values are the Pearson correlation coefficients

aExpectations towards the analgesic effects of alcohol

bEvaluated using the Michigan Alcoholism Screening Test

cEmotional abuse subscale from Childhood Trauma Questionnaire

dEvaluated using the Beck Depression Inventory

Serial mediation model

Figure 1 depicts the estimated non-standardized parameters for the serial mediation model. The alpha for all the reported P-values was .05. The model explained 10% of the variance in severity of depressive symptoms (R2 = .099; F[3205] = 7.492; P< .001), 15% of the variance in expectations towards analgesic effects of alcohol (R2 = .147; F[4204] = 8.753; P< .001), and 18% of the variance in AUD symptom severity (R2 = .184; F[5203] = 9.186; P < .001). Childhood emotional abuse was positively associated with severity of depressive symptoms, expectations towards analgesic effects of alcohol, and AUD symptom severity. Moreover, severity of depressive symptoms was positively associated with expectations towards analgesic effects of alcohol and AUD symptom severity. Finally, expectations towards analgesic effects of alcohol were positively associated with AUD symptom severity. The estimated parameters relating to a total effect, indirect effects, and contrasts between the indirect effects are shown in Table 3 (non-standardized coefficients are reported). There is statistical evidence supporting all three indirect effects. Namely, there is evidence for two simple mediated effects, whereby the severity of depressive symptoms mediates the association between childhood emotional abuse on AUD symptom severity, and expectations towards analgesic effects of alcohol mediate the association between childhood emotional abuse on AUD symptom severity. There is also evidence to support serial mediation whereby both severity of depressive symptoms and expectations towards the analgesic effects of alcohol mediate the association between childhood emotional abuse on AUD symptom severity. All the statistical associations are positive. As the direct effect of childhood emotional trauma on AUD symptom severity is also statistically significant (Fig. 1), the three indirect effects result in three partial mediation paths. The contrasts comparing all three indirect effects were not statistically significant. This indicates equal statistical support for all three partial mediation paths (Hayes 2013).

Non-standardized coefficients in the estimated serial mediation model.
Figure 1

Non-standardized coefficients in the estimated serial mediation model.

Table 3

Total effect, indirect effects, and contrasts between the indirect effects in the estimated serial mediation model

Effect typeEffectEffect sizeBootstrap LLCIBootstrap ULCI
Totalc0.1910.0730.331
Indirecta1b10.0970.0060.205
Indirecta2b20.0710.0060.169
Indirecta1db20.0240.0030.058
Contrasta1b1 - a2b20.026−0.1150.163
Contrasta1b1 - a1db20.073−.0250.185
Contrasta2b2 - a1db20.047−.0160.143
Effect typeEffectEffect sizeBootstrap LLCIBootstrap ULCI
Totalc0.1910.0730.331
Indirecta1b10.0970.0060.205
Indirecta2b20.0710.0060.169
Indirecta1db20.0240.0030.058
Contrasta1b1 - a2b20.026−0.1150.163
Contrasta1b1 - a1db20.073−.0250.185
Contrasta2b2 - a1db20.047−.0160.143

The letter and number designations of the effects match those shown in Fig. 1. Indirect effects: a1b1 = the effect of childhood emotional trauma on AUD symptom severity via severity of depressive symptoms, a2b2 = the effect of childhood emotional trauma on AUD symptom severity via expectations towards analgesic effects of alcohol, and a1db2 = the effect of childhood emotional trauma on AUD symptom severity via serial mediation.

Table 3

Total effect, indirect effects, and contrasts between the indirect effects in the estimated serial mediation model

Effect typeEffectEffect sizeBootstrap LLCIBootstrap ULCI
Totalc0.1910.0730.331
Indirecta1b10.0970.0060.205
Indirecta2b20.0710.0060.169
Indirecta1db20.0240.0030.058
Contrasta1b1 - a2b20.026−0.1150.163
Contrasta1b1 - a1db20.073−.0250.185
Contrasta2b2 - a1db20.047−.0160.143
Effect typeEffectEffect sizeBootstrap LLCIBootstrap ULCI
Totalc0.1910.0730.331
Indirecta1b10.0970.0060.205
Indirecta2b20.0710.0060.169
Indirecta1db20.0240.0030.058
Contrasta1b1 - a2b20.026−0.1150.163
Contrasta1b1 - a1db20.073−.0250.185
Contrasta2b2 - a1db20.047−.0160.143

The letter and number designations of the effects match those shown in Fig. 1. Indirect effects: a1b1 = the effect of childhood emotional trauma on AUD symptom severity via severity of depressive symptoms, a2b2 = the effect of childhood emotional trauma on AUD symptom severity via expectations towards analgesic effects of alcohol, and a1db2 = the effect of childhood emotional trauma on AUD symptom severity via serial mediation.

Discussion

Prior work has established that childhood emotional abuse is a critical risk factor for mental health in adulthood that warrants additional investigation. Current studies have highlighted the association of childhood emotional abuse and depressive symptoms, as well as their joint role in predicting the onset of AUD. In addition, the critical role of pain as a correlate of AUD has piqued researchers’ interest. Yet, investigation as to whether expectations towards the analgesic effects of alcohol use among individuals with AUD explains the link between childhood maltreatment and depressive symptomatology remains to be conducted. To the best of our knowledge, this is the first study to investigate associations between childhood emotional abuse and AUD symptom severity via depressive symptoms and expectations of the analgesic effect of alcohol on AUD symptom severity. The current study indicates that individuals who experienced emotional abuse in childhood might suffer from more depressive symptoms in adulthood. In turn, these individuals also have higher expectations that alcohol has analgesic effects, which then leads to a more severe course of AUD.

Previous studies on childhood maltreatment demonstrated that among all forms of abuse and neglect, emotional abuse might be the strongest correlate of depressive symptoms (Norman et al. 2012; Martins et al. 2014; Christ et al. 2019). Furthermore, a history of emotional abuse may contribute to other mental health problems, such as self-injuries, suicide attempts, and problematic alcohol use (Xiao et al. 2023). Our study extends existing knowledge on risk factors contributing to AUD symptom severity, as it focuses specifically on emotional abuse, since it may have more severe consequences than other forms of maltreatment. The association between emotional abuse and alcohol-related consequences may be explained by an indirect effect of urgency (Shin et al. 2015) or impaired control over drinking (Patock-Peckham et al. 2020). Our findings are in general agreement with previous work indicating that childhood emotional abuse is associated with AUD outcomes and depressive symptoms. Our study offers a novel contribution to this literature by demonstrating that severity of depressive symptoms may act as a potential mechanism linking childhood emotional abuse and AUD symptom severity.

In addition, prior work acknowledges that alcohol use outcome expectancies may contribute to one’s current drinking behavior. For example, positive alcohol use outcome expectancies are associated with greater alcohol consumption and with a higher frequency of negative outcomes as a result of alcohol use (Jones et al. 2001; Blume and Guttu 2015). Given that positive alcohol use outcome expectancies are related to more negative consequences of alcohol use, it follows that expectancies that alcohol will have an analgesic effect will be associated with greater negative alcohol use outcomes (LaRowe et al. 2021). Prior work examining the role of alcohol analgesia effects on problematic alcohol use among individuals without chronic pain is relatively lacking despite some initial support for an association between higher alcohol analgesia expectancies and heavier drinking among individuals without chronic pain (LaRowe et al. 2022). Prior work has also tended to focus on drinking behavior and drinking outcomes in non-clinical groups. Our study extends this work by examining expectancies that alcohol will have an analgesic effect in a sample of individuals with AUD. Our findings demonstrate that individuals that believe that alcohol has analgesic effects are more likely to report higher AUD symptom severity.

Among all forms of maltreatment, emotional abuse tends to have a unique impact on pain-related outcomes. It was shown that it significantly predicts unexplained chest pain (Eslick et al. 2011) and pain catastrophizing (Delgado-Sanchez et al. 2023), while other forms of maltreatment did not evince this effect. In the current study, findings support a link between childhood emotional abuse and greater alcohol analgesic effect expectancies. Indeed, those expectancies partially mediate the association between childhood emotional abuse and AUD symptom severity of AUD.

Childhood and adolescence are critical periods with regard to developing alcohol use expectancies. For example, Copeland et al. (2014) observed that positive alcohol expectancies among students in 2nd to 6th grade were actively changing during an 18-month observation period. Accordingly, they identified pre-adolescence to be crucial in molding drinking behavior. Moreover, other studies support the premise that alcohol expectancies are formed even before age 12 (Miller et al. 1990). So, if it is known that childhood is a critical period to develop expectancies towards alcohol use, there is a critical need to examine whether severe disturbances in development, such as childhood maltreatment, will influence the formation of these expectancies. Cranford et al. (2010) demonstrated that alcohol expectancies in early adolescence (10 to 14 years old) predicted frequency of alcohol use in middle adolescence (15 to 17 years old). More specifically, higher positive alcohol use expectancies were related to higher frequency of alcohol use, and higher negative expectancies resulted in lower frequency of alcohol use.

An interesting and novel result of our study is an observed significant association between higher severity of depressive symptoms and higher expectations towards analgesic effects of alcohol. This association aligns with other studies supporting an association between negative affect and utilization of alcohol or other substances as a coping strategy to obtain an expected relief (Vowles et al. 2018; Nieto et al. 2021). It is possible that expectations for relief might increase with the rise of negative affect if alcohol (or another drug) has been identified as a viable means to achieve relief. The use of alcohol as a plausible source of relief may be specifically heightened among individuals with behavioral control deficits (as manifested by high impulsivity) reported in numerous studies using AUD samples (e.g. Jakubczyk et al. 2018). These findings are also consistent with results from Kwako et al. (2019) who distinguished three main neurofunctional domains engaged in the addictive cycle: incentive salience, negative emotionality, and executive function (executive control). Accordingly, in this study all of these factors were demonstrated to be associated with early-life stress.

Our study may be one of the first to assess the association between depression and expectations towards specific relief from physical pain, which constitutes both somatic and mental suffering (Peters 2015), as a link between childhood emotional abuse and subsequent AUD symptom severity in a clinical sample of individuals with AUD. Importantly, this association might be bidirectional (i.e. patients having higher analgesic expectations might drink more and as a consequence become more depressed). This remains unclear with this cross-sectional design of the study and therefore might be an interesting subject for further, longitudinal investigations. While our research question referred directly to analgesic expectancies towards physical pain, in real life it may be difficult to distinguish somatic from emotional pain as sensory and affective components often contribute to the multifaceted experience of pain simultaneously (Navratilova and Porreca 2014). In our model, depressive symptoms may represent emotional pain (negative affect) emphasizing a strong connection between these (emotional and physical) domains. However, as mentioned previously, alcohol may be used to reduce both somatic and emotional components of pain (Edwards et al. 2020), which might explain its common use as a coping strategy in both – somatic and emotional conditions.

As it has been discussed, acquiring alcohol-related knowledge, beliefs and expectancies takes place in middle childhood to early adolescence, which impacts future drinking behavior. Moreover, a positive attitude towards alcohol, which typically increases with age, precedes drinking onset. Since alcohol-related expectations and attitudes arise before alcohol initiation, education about the possible negative consequences of alcohol use should be provided in this critical period of child development. Efforts to reduce positive alcohol use expectancies should be addressed in alcohol use prevention strategies (Jones and Gordon 2017; Montes et al. 2019). Our results suggest that implementing prevention strategies focused on alcohol analgesia expectancies might be particularly valuable, especially among youth with histories of maltreatment. Addressing positive expectancies towards alcohol use may also be a promising target for use in AUD treatment. Prior work indicates that Cognitive-Behavior Therapy for AUD patients that address alcohol use expectations was found to lower positive patients’ expectations for tension reduction after alcohol use, which was also associated with more abstinent days after treatment (Coates et al. 2018). In our study, we highlight the contribution of expectancies that alcohol will have an analgesic effect on greater severity of AUD symptoms. Since positive alcohol use expectancies are considered a target for therapeutic interventions, our findings indicate that addressing expectancies that alcohol will have an analgesic effect may have significant utility for patients with AUD. Furthermore, those interventions may be particularly beneficial for patients who also endorse a history of childhood emotional abuse.

Several study limitations are worth noting. Our study includes individuals participating in an inpatient AUD treatment program. Thus, the study sample includes patients with a severe course of AUD. Although our results are encouraging, future work should assess whether similar pathways are also relevant among patients with mild or moderate AUD symptom severity. In addition, males comprise the majority of the study sample, so future work should test similar models with female participants, as well as assess possible sex differences. Although patients with tobacco use disorder were enrolled in the study, we did not assess nicotine dependence severity and did not control for this variable in our statistical model. Given that childhood emotional abuse was measured by a self-report questionnaire, there are limits with regard to recall bias. The current study is based on cross-sectional data. Thus, it will be important to replicate these associations with prospective data that can account for temporal precedence. Expectancies that alcohol will have an analgesic effect was assessed with one self-report item rated on a five-point Likert scale. Future research should test whether findings replicate with a multiple-item measure of alcohol use expectancies, such as the five-item Expectancies for Alcohol Analgesia questionnaire developed by LaRowe et al. (2021). Our model explains only 10% of the variance in severity of depressive symptoms, 15% of the variance in expectancies that alcohol will have an analgesic effect, and 18% of the variance in AUD symptom severity. Therefore, there are presumably other factors that affect these specific constructs that should be taken into consideration in alternative models (e.g. chronic pain, or pain-related conditions). Nevertheless, to the authors’ knowledge, this is the first study to investigate associations between childhood emotional abuse, severity of depressive symptoms, and expectancies that alcohol will have an analgesic effect in individuals with AUD. Our results provide support for positive direct associations between childhood emotional abuse, expectancies that alcohol will have an analgesic effect, severity of depressive symptoms, and severity of AUD symptoms. Furthermore, it supports indirect effects – childhood emotional abuse on severity of AUD symptoms via severity of depressive symptoms, childhood emotional abuse on severity of AUD symptoms via expectancies that alcohol will have an analgesic effect, and childhood emotional abuse on severity of AUD symptoms via serial mediation. Our results offer an understanding of the complex role that childhood emotional abuse and expectancies that alcohol will have an analgesic effect may have on AUD symptom severity.

Acknowledgements

We would like to thank all patients from Addiction Treatment Center who participated in the study.

Author Contributions

All authors contributed to the conception and design of the work. JZ, JS, MW, MK, AJ contributed to the acquisition of data. MK, EMT, PK, JS provided analysis and interpretation of data. JZ and AJ managed the literature research and wrote the first draft of manuscript. EMT, MW, MK, JS revised the manuscript and provided substantial input. All authors approved content of final version of the manuscript.

Conflict of Interest

No conflict declared.

Funding

This study was supported by the National Science Centre grant (2017/25/B/HS6/00362; PI: Jakubczyk).

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

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