Co-occurring aggression and suicide attempt among veterans entering residential treatment for PTSD: The role of PTSD symptom clusters and alcohol misuse

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Abstract

Aggression and suicidality are two serious public health concerns among U.S. veterans that can co-occur and share many overlapping risk factors. The current study aims to elucidate the contribution of posttraumatic stress disorder (PTSD) symptom clusters defined by a five-factor model and alcohol misuse in predicting aggression and suicide attempts among veterans entering residential treatment for PTSD. Participants were 2570 U.S. veterans across 35 Veterans Health Administration sites. Multinomial logistic regression models were used to identify correlates of aggression only (n = 1471; 57.2%), suicide attempts only (n = 41; 1.6%), co-occurring aggression and suicide attempts (n = 202; 7.9%), and neither behavior (n = 856; 33.3%) over the past four months. When compared to veterans endorsing neither behavior, greater PTSD re-experiencing symptoms were related to suicide attempts (odds ratio [OR] = 1.58, 95% confidence interval [CI] = 1.09–2.30), aggression (OR = 1.13, 95% CI = 1.02–1.26), and co-occurring aggression and suicide (OR = 1.38, 95% CI = 1.13–1.68), and higher PTSD dysphoric arousal symptoms and alcohol misuse symptoms were related to aggression (OR = 1.54, 95% CI = 1.38–1.71; OR = 1.30, 95% CI = 1.18–1.44, respectively) and co-occurring aggression and suicide (OR = 1.66, 95% CI = 1.35–2.04; OR = 1.50, 95% CI = 1.28–1.75, respectively). Our findings suggest that assessment of PTSD symptom clusters and alcohol misuse can potentially help to identify veterans who endorse suicide attempts, aggression, or both concurrently. These results have important implications for risk assessment and treatment planning with U.S. veterans seeking care for PTSD.

Introduction

Aggression and suicide attempts are two serious public health concerns among U.S. veterans. Treatment-seeking veterans report high levels of aggression (Taft et al., 2009) and are estimated to have suicide rates 50% higher than civilians (Blow et al., 2012, McCarthy et al., 2009). Further, interpersonal aggression and suicidal ideation often co-occur among veterans and have many overlapping risk factors (Hellmuth et al., 2012). However, current knowledge about the overlap between aggression and suicide attempts and risk factors for the co-occurrence of these behaviors among clinical populations is limited. This information is important, as it can inform effective treatment-planning and prevention strategies for these two harmful behaviors (Elbogen et al., 2010). Among treatment seeking veterans, two of the most commonly recognized risk factors for both aggression and suicidality are PTSD symptoms (Ashrafioun et al., 2016, Elbogen et al., 2014, Pietrzak et al., 2010) and alcohol misuse (Elbogen et al., 2014, Maguen et al., 2015). The current study aims to elucidate the unique contributions of PTSD symptom clusters and alcohol misuse to differentiate veterans who engage in aggression and/or suicide attempts.

Although PTSD diagnosis and symptom severity have been indicated as risk factors for aggressive and suicidal behavior (Elbogen et al., 2014, Pietrzak et al., 2010), less is known about how particular components of PTSD, which is a heterogeneous disorder characterized by re-experiencing, avoidance, emotional numbing, and dysphoric and anxious arousal symptoms (Harpaz-Rotem et al., 2014), may relate to these two behaviors. A more nuanced examination of PTSD symptoms may help clarify which specific facets of PTSD are most related to risk for aggression and/or suicide attempt. In support of this notion, prior research examining specific PTSD symptoms has shown that certain clusters appear to be differentially related to aggression (Barrett et al., 2014, Taft et al., 2007) and suicidality (Bryan and Anestis, 2011, Selaman et al., 2014). Specifically, PTSD arousal or hyperarousal symptoms may intensify individuals’ responses to anger provoking situations (Sullivan and Elbogen, 2014, Zillman et al., 1972). In fact, past findings suggest that hyperarousal symptoms are associated with marital violence among veterans (Savarese et al., 2001) and several studies have suggested that when compared to avoidance and re-experiencing symptoms, hyperarousal symptoms are more strongly related to aggression among civilians and veterans (Barrett et al., 2014, Taft et al., 2007). Regarding suicidality, empirical evidence suggests that DSM-IV re-experiencing and avoidance symptoms play important roles (Selaman et al., 2014). Re-experiencing symptoms have similarities to mental rehearsal of painful and provocative experiences, and as suggested by Joiner (2005), mental rehearsal of painful experiences (such as traumatic events) may play a key role in acquired capability for suicide, increasing the risk for a suicide attempt. Consistent with this idea, Bell and Nye (2007) found that re-experiencing symptoms were associated with suicidal ideation, while hyperarousal and avoidance symptoms were not. Further, Bryan and Anestis (2011) found that re-experiencing symptoms had an indirect link to suicidal desire (through a global mental health score) and a direct association with acquired capability for suicide. Other evidence and theoretical work suggests that avoidance symptoms, particularly emotional numbing symptoms, may be related to suicide attempts because of these symptoms association with social impairment, isolation, and relationship dissatisfaction (Joiner, 2005, Lunney and Schnurr, 2007). Indeed, Selaman et al. (2014) found that both DSM-IV re-experiencing and avoidance symptoms were associated with suicide attempts. Thus, when considered together, PTSD arousal symptoms may be more strongly related to aggression whereas re-experiencing and avoidance symptoms, particularly emotional numbing symptoms, more closely linked to suicide attempts. However, we are not aware of research that has simultaneously examined how particular PTSD symptoms may relate to suicide attempts, aggression, or both behaviors concurrently. Further, studies examining associations between avoidance symptoms and suicidality have not discriminated between emotional numbing symptoms and behavioral avoidance (e.g., Selaman et al., 2014).

Recent research suggests that a five-factor PTSD model (Elhai et al., 2011) provides a better representation of PTSD symptom dimensionality than four-factor models among various populations and trauma types both in civilians and veterans (Armour et al., 2015, Harpaz-Rotem et al., 2014, Pietrzak et al., 2012). Similar to the four-factor emotional numbing model (King et al., 1998), this five-factor model includes a re-experiencing (e.g., intrusive thoughts, recurrent dreams), avoidance (e.g., avoiding thoughts and reminders of trauma), and emotional numbing (e.g., loss of interest, detachment) factors. This more nuanced model also distinguishes a dysphoric arousal factor and an anxious arousal factor. The dysphoric arousal factor is posited to represent general distress and includes difficulty sleeping, irritability/anger, and difficulty concentrating, which were included in a hyperarousal (King et al., 1998) or a dysphoria factor (Simms et al., 2002) in previous four-factor models. The anxious arousal factor is theorized to be more physiological- and fear-based and includes being overly alert and easily startled. The dysphoric arousal factor may be more strongly related to the occurrence of aggression, because anger-related distress is associated with approach motivation and offensive aggression (attacks and no attempts to escape), whereas fear is associated with avoidance motivation and defensive aggression, in which attacks only occur when escape is impossible (Adams, 2006, Blanchard and Blanchard, 1984, Carver and Harmon-Jones, 2009, Harmon-Jones and Sigelman, 2001, Moyer, 1976). However, no previous research has examined these arousal factors separately in regards to aggression or suicide attempts. This more nuanced model could help inform risk assessment and more personalized treatment approaches for these two harmful behaviors.

In addition to PTSD, alcohol misuse has been implicated as a risk factor both aggression and suicidal behavior among veterans (Maguen et al., 2015). Alcohol has disinhibiting effects, potentially causing individuals to be more likely to act on aggressive and/or suicidal urges when intoxicated (Giancola et al., 2010). Alcohol misuse and alcohol use disorders have been repeatedly linked to greater risk for aggression and violence among veterans (Elbogen et al., 2014, Taft et al., 2007). Although a majority of research indicates a link between alcohol misuse and suicidality among veterans (Kim et al., 2012, Maguen et al., 2015, Pietrzak et al., 2010), a recent study did not find an association between alcohol dependence and heavy drinking, and past-year suicide attempts among veterans referred from primary care for a mental health evaluation (Ashrafioun et al., 2016). The reason for this discrepancy in findings is unclear, but could be due to differences in samples (only Ashrafioun et al. used a primary care sample) or that Ashrafioun et al. used suicidal ideators as a reference group for attempters, which is more stringent than non-attempters. Further research is needed to clarify the relationship between alcohol misuse and suicide attempts among veterans, particularly among those presenting for mental health treatment. Additionally, the role of alcohol misuse as a contributing factor to co-occurring aggression and suicidal behavior has yet to be extrapolated.

In sum, particular PTSD symptoms and alcohol misuse have both been identified as risk factors for aggression and suicidal behavior. However, little research has been conducted on the unique contributions of PTSD symptoms and alcohol misuse to increased risk for engaging in aggression, suicide attempts, or both behaviors concurrently. In the few studies that have examined PTSD, alcohol, suicidality, and aggression together, all have focused on suicidal ideation rather than suicide attempts (e.g., Hellmuth et al., 2012). This is an important distinction, because most suicide ideators do not attempt suicide (Nock et al., 2008) and therefore, results based on ideation may not generalize to actual suicide attempts. The aim of the current study is to elucidate the unique contributions of alcohol misuse and PTSD symptom clusters, conceptualized with a nuanced five-factor model (Elhai et al., 2011), to differentiate veterans entering residential treatment for PTSD who engage in aggression, suicide attempts, or both aggression and suicide attempts concurrently. We hypothesized that greater dysphoric arousal would be related to increased likelihood of aggressive behavior. We expected that greater re-experiencing and emotional numbing symptoms would be related to increased likelihood of suicide attempts and that greater alcohol misuse would be related to increased likelihood of both aggression and suicide attempts.

Section snippets

Participants

Participants were U.S. veterans who completed a self-report measure of PTSD symptoms upon admission to residential treatment for PTSD across 35 Veterans Health Administration sites as part of a VA program evaluation process. Veterans entered treatment between April 2012 and May 2013. Veterans endorsed serving in the following war eras (veterans were allowed to select more than one category so percentages do not add up to 100%): 1282 (49.9%) selected Operation Iraqi Freedom/Operation Enduring

Results

The numbers of veterans in each group were as follows: 856 (33.3%) endorsed neither suicide attempt nor aggressive behavior, 41 (1.6%) endorsed suicide attempt only, 1471 (57.2%) endorsed aggression only, and 202 (7.9%) endorsed both suicide attempt and aggressive behavior. Descriptive information for PTSD symptoms and alcohol misuse are displayed in Table 1.

The likelihood ratio tests for the independent variables that were entered in a multinomial logistic regression with behavioral

Discussion

The purpose of the current study was to examine the contributions of PTSD symptoms, using a nuanced five-factor model, and alcohol misuse in relation to suicide attempts, aggression, and concurrent suicidal and aggressive behaviors in a sample of veterans in residential treatment for PTSD. We found that the majority of veterans endorsed aggressive behavior only (57.2%), a sizable minority (7.9%) of veterans reported concurrent suicide attempt and aggressive behavior, and only 41 veterans (1.6%)

Conflicts of interest

None.

Contributors

Drs. Hoff and Harpaz-Rotem acquired the data. Dr. Watkins conducted the statistical analyses. Dr. Harpaz-Rotem provided guidance on statistical analyses. Drs. Watkins and Sippel drafted the manuscript. Drs. Watkins, Sippel, Pietrzak, Hoff, and Harpaz-Rotem, contributed to conceptualizing the study, interpreting the findings, and revising the manuscript. All authors have approved the final version of this manuscript.

Role of funding source

No funding source had a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Acknowledgment

Preparation of this manuscript was supported in part by the Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, the Department of Veterans Affairs National Center for Posttraumatic Stress Disorder Clinical Neurosciences Division, and VA Connecticut Healthcare System.

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