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There is a lack of longitudinal studies measuring the naturalistic development of PTSD and alcohol use problems in individuals with recent trauma exposure. This study aimed to compare the temporal relationships between posttraumatic stress symptoms and alcohol use over 6\u2009months following trauma exposure in males and females.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Large\u2010scale longitudinal observational emergency department (ED)\u2010based study of individuals with recent trauma exposure. Individuals with recent trauma exposure (<jats:italic>n<\/jats:italic>\u2009=\u20092942, 62% female) were recruited from 29 EDs across the United States within 72\u2009h of trauma exposure from 2017 to 2021. PTSD symptoms, measured via the PTSD Checklist for the DSM\u20105, and alcohol use measured via the PhenX toolkit, were assessed at five time points: ED visit, 2\u2009weeks, 8\u2009weeks, 3\u2009months, and 6\u2009months following trauma.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>PTSD symptoms predicted lower future alcohol use between the pretrauma to two\u2010week time points (<jats:italic>b<\/jats:italic>\u2009=\u2009\u22120.08, <jats:italic>p<\/jats:italic>\u2009=\u20090.01) and higher use between the 3\u2010 to 6\u2010month time points (<jats:italic>b<\/jats:italic>\u2009=\u20090.06, <jats:italic>p<\/jats:italic>\u2009=\u20090.01). There were no time points in which alcohol use predicted future PTSD symptoms. When stratifying by sex, male participants showed reciprocal associations, with alcohol use early after trauma predicting PTSD symptoms between 2 and 8\u2009weeks (<jats:italic>b<\/jats:italic>\u2009=\u20090.08, <jats:italic>p<\/jats:italic>\u2009=\u20090.01), while PTSD symptoms predicted alcohol use between the 3\u2010 to 6\u2010month time points (<jats:italic>b<\/jats:italic>\u2009=\u20090.10, <jats:italic>p<\/jats:italic>\u2009=\u20090.01). Female participants showed a different reciprocal pattern, with pretrauma PTSD symptoms predicting lower alcohol use 2\u2009weeks posttrauma (<jats:italic>b<\/jats:italic>\u2009=\u2009\u22120.08, <jats:italic>p<\/jats:italic>\u2009=\u20090.04), while alcohol use subsequently predicted greater PTSD symptoms from 8\u2009weeks to 3\u2009months (<jats:italic>b<\/jats:italic>\u2009=\u20090.04, <jats:italic>p<\/jats:italic>\u2009=\u20090.04); these findings did not survive Bonferroni correction.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Males and females exhibit complex temporal development patterns of PTSD symptoms and alcohol use that align with the mutual maintenance hypothesis in males but the susceptibility hypothesis in females. These patterns are masked in analyses that do not stratify by sex.<\/jats:p><\/jats:sec>","DOI":"10.1111\/acer.70092","type":"journal-article","created":{"date-parts":[[2025,6,6]],"date-time":"2025-06-06T04:10:07Z","timestamp":1749183007000},"page":"1504-1517","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["The reciprocal relationship between posttraumatic stress disorder symptoms and alcohol use in a large multisite longitudinal sample stratified by sex: A random\u2010intercept cross\u2010lagged panel model"],"prefix":"10.1111","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2577-6142","authenticated-orcid":false,"given":"Cecilia A.","family":"Hinojosa","sequence":"first","affiliation":[{"name":"Department of Psychiatry and Behavioral Sciences Emory University School of Medicine  Atlanta Georgia USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sanne J. 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