Direct and indirect relationships among posttraumatic stress disorder,depression, hostility,anger, and verbal and physical aggression in returning veterans

Hostility, anger, and aggression are conceptually related but unique constructs found to occur more often among veterans with posttraumatic stress disorder (PTSD) than among civilians or veterans without PTSD. However, the pathways between PTSD, depression, hostility, anger, and aggression have not been comprehensively characterized. Therefore, drawing on a sample of returning Operation Enduring Freedom/Operation Iraqi Freedom combat veterans ( N = 175; 95% male; mean age 30 years), this study sought to examine the direct and indirect relationships among PTSD, depression, hostility, anger, and four types of aggression: verbal, and physical toward self, others, and objects. Functional modeling of direct effects was done using multiple least-squares regression and bootstrapped mediation analyses were carried out to test indirect effects. Results indicate that PTSD is not the overall direct contributor to different forms of aggression, supporting the mediating role of depression and trait anger. Depression symptoms explain part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward self and trait anger explains part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward others. Our findings support the importance of assessing for anger, depression, and different types of aggression among veterans presenting for PTSD treatment to develop individualized treatment plans that may benefit from early incorporation of interventions.     

Combat readiness: Perceived influences on willingness to deploy

This study investigated the association between combat readiness and soldiers’ willingness to deploy in operations. Participants were 465 members of the South African National Defence Force (SANDF) (males, 84%). The solders self-reported their perceived combat readiness (PCR) and willingness to deploy (WD) in peace-keeping operations. The correlational analysis results PCR and WD were related with the inclusion of the dimensions support to the family, confidence in self, the team, leaders and training, high morale and esprit de corps. Horizontal and vertical cohesion positively influenced WD, and not unit discipline.     

The cycle of violence as a function of PTSD and appetitive aggression: A longitudinal study with Burundian soldiers

During deployment, soldiers face situations in which they are not only exposed to violence but also have to perpetrate it themselves. This study investigates the role of soldiers' levels of posttraumatic stress disorder (PTSD) symptoms and appetitive aggression, that is, a lust for violence, for their engaging in violence during deployment. Furthermore, factors during deployment influencing the level of PTSD symptoms and appetitive aggression after deployment were examined for a better comprehension of the maintenance of violence. Semi-structured interviews were conducted with 468 Burundian soldiers before and after a 1-year deployment to Somalia. To predict violent acts during deployment (perideployment) as well as appetitive aggression and PTSD symptom severity after deployment (postdeployment), structural equation modeling was utilized. Results showed that the number of violent acts perideployment was predicted by the level of appetitive aggression and by the severity of PTSD hyperarousal symptoms predeployment. In addition to its association with the predeployment level, appetitive aggression postdeployment was predicted by violent acts and trauma exposure perideployment as well as positively associated with unit support. PTSD symptom severity postdeployment was predicted by the severity of PTSD avoidance symptoms predeployment and trauma exposure perideployment, and negatively associated with unit support. This prospective study reveals the importance of appetitive aggression and PTSD hyperarousal symptoms for the engagement in violent acts during deployment, while simultaneously demonstrating how these phenomena may develop in mutually reinforcing cycles in a war setting.     

Functional Impairment as a Variable in Adjustment Post-Combat

This study examined how functional impairment relates to postcombat adjustment over time, controlling for the influence of combat exposure. Analyses used sequential random coefficient models to examine 2 hypotheses: a) combat exposure and functional impairment predict the change in posttraumatic stress, depression, and anger/aggression symptoms during the first year postcombat; and b) combat exposure and functional impairment at reintegration predict symptom scores at 1 year postdeployment. A Brigade Combat Team completed surveys at reintegration, 4 months, and 12 months after a 1-year deployment to Iraq. Soldiers reporting high functional impairment at reintegration had higher symptoms at both follow-up periods, and functional impairment was a significant predictor of symptoms at the last time point, even after accounting for the influence of combat exposure. There was also an interaction effect, such that functional impairment exacerbated the impact of combat exposure on posttraumatic stress and anger/aggression symptoms at 12 months postdeployment.     

USAF Special Tactics Operator Combat Exposure and Psychological Stress

Given the length of combat in Afghanistan, Iraq, Syria, and elsewhere, and the role special operations forces will continue to play, we believe it is imperative to gain understanding of the psychological “wear and tear” associated with sustained combat operations on these highly specialized, highly utilized personnel. This study focused on a seldom-studied group, Air Force Special Tactics (ST) operators, to assess combat exposure, current psychological stress, and preferences for support when needed. This study assessed symptoms of posttraumatic stress, depression, anxiety, sleep, anger, and perceptions of help seeking in 5 ST units. Data revealed that the majority of study participants report distress levels below clinical thresholds; however, 26% struggle with generalized stress/agitation and, at smaller percentages, other distress symptoms that have negative impact on work performance. Combat experiences were comparable or higher than Army and Marine maneuver forces, and greater amounts of exposure related to positive screening for a possible mental health disorder, generalized agitation, and posttraumatic symptoms; combat involving direct fighting and being in high-threat situations were also related to posttraumatic stress. Distress rates for Special Operations Weather personnel were higher. Attitudes toward mental health support were positive however, embedded assets were preferred over base clinic providers. We review these and other findings and offer suggestions for future research in this area.     

Moderating Effect of Marital Status on the Association Between Combat Exposure and Post-Deployment Mental Health in Canadian Military Personnel

For military personnel, there are positive and negative aspects of marriage, which may contribute to mental health during times of high stress. The present study investigated the relationship of marital status with three mental health outcomes (general mental health, posttraumatic stress disorder [PTSD], depression) among 14,624 Canadian military personnel recently deployed in support of the mission in Afghanistan. Greater combat exposure was associated with poorer postdeployment mental health, but marital status was, on its own, only slightly associated with PTSD. Marital status significantly moderated the relationship between combat exposure and mental health: For both single and married participants, mental health declined as combat exposure increased, but this association was stronger for married members. This association could be due to the additional familial demands that married personnel may face upon their return from deployment or to the stresses associated with poor marital satisfaction. Overall, results suggest that the relationship between marital status and mental health after deployment is complex and may vary according to other factors.     

Combat veterans' symptoms of PTSD and partners' distress: the role of partners' perceptions of veterans' deployment experiences

Romantic partners of combat veterans with posttraumatic stress disorder (PTSD) report elevated relationship and psychological distress. One recent study suggests that this association may be weaker when partners perceive that veterans experienced higher levels of traumatic deployment events, but such results have not yet been replicated. We replicated and extended these findings in a sample of 206 National Guard service members who deployed overseas since 2001 and their partners. We used multivariate structural equation models to explore whether partners' perceptions of service members' deployment experiences moderated the associations of severity of service members' overall PTSD and specific PTSD clusters with partners' psychological and relationship distress. The significant association of overall PTSD symptom severity with partners' distress was not moderated by partners' perceptions. When examining PTSD symptoms at the cluster level, only the numbing/withdrawal cluster was significantly associated with distress. However, this association was moderated by partners' perceptions of service members' deployment experiences, such that the associations weakened as these perceptions increased. These results are in line with research indicating that the avoidance cluster of PTSD symptoms is particularly detrimental for partners of those with PTSD. Furthermore, they indicate that such symptoms are associated with less distress in partners who perceive that service members experienced high levels of potentially traumatic deployment events. Such perceptions may be linked with external attributions for symptoms, which suggests that psychoeducation regarding the causes of PTSD and the totality of PTSD symptoms may be useful in intervening with such partners.     

Moral transgression during the Vietnam War: a path analysis of the psychological impact of veterans’ involvement in wartime atrocities

Background and Objectives: Involvement in wartime combat often conveys a number of deleterious outcomes, including posttraumatic stress disorder (PTSD), depression, hostility, aggression, and suicidal ideation. Less studied is the effect of engagement in wartime atrocities, including witnessing and perpetrating abusive violence.

Design and Methods: This study employed path analysis to examine the direct effects of involvement in wartime atrocities on hostility, aggression, depression, and suicidal ideation independent of combat exposure, as well as the indirect effects via guilt and PTSD symptom severity among 603 help-seeking male Vietnam War veterans.

Results: Involvement in wartime atrocities was predictive of increased guilt, PTSD severity, hostility, aggression, depressive symptoms, and suicidal ideation after controlling for overall combat exposure. Combat-related guilt played a minor role in mediating the effect of atrocity involvement on depression and suicidal ideation. PTSD severity had a larger mediational effect. However, it still accounted for less than half of the total effect of involvement in wartime atrocities on hostility, aggression, and suicidal ideation.

Conclusions: These findings highlight the heightened risk conveyed by involvement in wartime atrocities and suggest that the psychological sequelae experienced following atrocity involvement may extend well beyond guilt and PTSD.     

Internal Anger and External Expressions of Aggression in OEF/OIF Veterans

National Guard/Reserve service members (n?=?143) deployed to Operations Enduring/Iraqi Freedom completed measures of anger/aggression, coping, and PTSD. Regressions and path analyses revealed that PTSD and avoidant coping both contributed to elevated anger. Furthermore, PTSD exerted indirect effects on verbal and physical aggression via anger, with direct effects only on physical aggression. Younger age was unrelated to anger but directly related to greater verbal and physical aggression. These results contribute to a more comprehensive understanding of risk for aggression in veterans of recent conflicts; however, the generalizability is limited by sample characteristics (all National Guard/Reserve, mostly White, married, religious).     

Sleep Disturbances Among Combat Military Veterans: A Comparative Study Using Subjective and Objective Sleep Assessments

The sleep characteristics of 37 military veterans and active-duty service members (17 with PTSD and 20 without PTSD) of recent wars were analyzed to determine if combat deployment, with its associated sleep restriction, may be an alternative explanation for the sleep complaints found among combat veterans with PTSD (as determined by PTSD Checklist Military Version scores). Over a 1-week period, sleep data were collected using sleep actigraphy and self-report. Across the entire sample, subjective and objective assessment methods of sleep were strongly correlated, although there were some notable within-group differences. Specifically, although sleep duration between groups did not differ based on actigraphy, veterans without PTSD reported sleeping 1 h and 11 min (p = .002) longer than did veterans with PTSD. In an effort to determine why individuals without PTSD might be overreporting sleep, we found that symptoms of emotional arousal (anger, anxiety, and nightmares) were significantly correlated with self-reported sleep duration, suggesting a pattern of higher autonomic arousal found in veterans with PTSD. Thus, although sleeping for 6 h, the higher levels of emotional arousal reported by veterans with PTSD may mean that they do not perceive their sleep as restful. Further research is necessary to determine if the sleep architecture of veterans with PTSD is actually different from that of combat veterans without PTSD and if such differences are actually amenable to standard behavioral treatments for this disorder.     

Psychopathic Personality Traits as Protective Factors against the Development of Post-Traumatic Stress Disorder Symptoms in a Sample of National Guard Combat Veterans

Military personnel often experience post-traumatic stress symptoms following exposure to combat. Personality traits have been identified as possible protective and risk factors in the development of post-traumatic stress disorder (PTSD), and examination of the association between PTSD and personality characteristics provides further insight into this heterogeneous disorder. Psychopathy, frequently conceptualized as collection of pathological personality disturbances relating to deficits in emotionality, empathy, and inhibitory control, includes within its defining features components that may be adaptive in certain situations. In the current study, we sought to expand upon the literature related to personality and PTSD by exploring psychopathic traits as resiliency factors in a military sample. Specifically, facets of psychopathy were analyzed as moderators of the association between combat experience and symptoms of post-traumatic stress disorder within a sample of 292 combat-exposed National Guard and Reserve (NGR) service members. Results indicated that the relationship of combat exposure with PTSD decreased as rates of interpersonal-affective psychopathic traits increased. Impulsive-antisocial traits were also found to moderate the association between combat experience and PTSD, though interestingly there was a similar decrease in magnitude with higher levels of these traits. These findings suggest that particular components of psychopathy may serve as protective factors against the development of PTSD symptomatology within this population.     

The Relationship Between Childhood Trauma,Combat Exposure,and Posttraumatic Stress Disorder in Male Veterans

The current study investigated the effects of combat exposure, childhood trauma, and depression on posttraumatic stress disorder (PTSD) severity. Participants were 299 male veterans from the Korean War, World War II, Vietnam, and the first Gulf War who were being screened for admission to the PTSD unit. Participants were assessed with the Clinician-Administered PTSD Scale (CAPS), Combat Exposure Scale (CES), Hamilton Depression Rating Scale (HAMD), Childhood Trauma Questionnaire (CTQ), and Mississippi Scale for PTSD (MPTSD). Results of multiple regression analyses indicated that, as expected, combat exposure and depression were significant predictors of PTSD severity. When examined with combat exposure, childhood trauma has a complex relationship to PTSD severity. Examination of the interaction between the CES and CTQ suggests that when levels of combat are low and childhood trauma levels are high, the CTQ is related to higher levels of PTSD severity on the CAPS, regardless of depression. Treatment implications are discussed.     

Coping with Gulf War combat stress: mediating and moderating effects

The authors examined relationships between method of coping with combat-related stress and psychological symptoms among Gulf War Army personnel (N = 1,058). Participants were surveyed on return from the Gulf region (Time 1) with the Coping Responses Inventory (R. Moos, 1990) and a measure of combat exposure. Outcomes were symptom measures of posttraumatic stress disorder (PTSD) and depression. At Time 2 (18-24 months) participants completed the same symptom measures and an index of postwar stress. Higher proportions of approach-based coping in the war zone were related to lower levels of psychological symptoms. Combat exposure moderated the effects of coping on Time 1 PTSD. Coping predicted changes in symptoms of depression but not PTSD. Combat exposure affected changes in depression through postwar stress but had a direct negative effect on PTSD.     

Personality traits as moderators of the associations between deployment experiences and PTSD symptoms in OEF/OIF service members

Abstract

This investigation examined traits from the five-factor model of personality as moderators of the associations of combat and aftermath of battle experiences with symptoms of posttraumatic stress disorder (PTSD) in 214 National Guard/Reserve service members deployed to operations enduring and Iraqi freedom. Extraversion significantly moderated the associations of both combat experiences and aftermath of battle experiences with PTSD severity, with associations weakening as levels of extraversion increased. The relation between aftermath of battle experiences and PTSD was also moderated by the other four personality factors, with the relation being weaker at higher levels of agreeableness, conscientiousness, and openness, and lower levels of neuroticism. These results suggest that personality traits may impact individual responses to war trauma, particularly war-related experiences that are not directly threatening to one's safety (i.e., aftermath of battle events vs. actual combat events). Although this investigation was cross-sectional, these findings indicate that personality traits are an important risk/resiliency factor to consider in people's responses to traumatic events.     

Social‐cognitive mediators of the relation of environmental and emotion regulation factors to children's aggression

Tested a theoretical model in which social cognitions about aggression partially mediated the relation of environmental and emotion regulation factors to children's aggressive behavior. An ethnically diverse sample of 778 children (57% girls) in grades 4–6 from both urban and suburban schools participated. Measures included exposure to aggression (seeing/hearing about aggression, victimization), emotion regulation (impulsivity, anger control), social cognitions about aggression (self‐evaluation, self‐efficacy, retaliation approval, aggressive fantasizing, caring about consequences), and aggressive behavior. Results supported the hypothesis that social cognitions mediate the relations of exposure to aggression and anger control to aggressive behavior. Also, social cognitions about direct and indirect aggression differentially predicted the respective behaviors with which they are associated. That is, social cognitions about direct aggression were mediators of direct aggressive behavior, whereas social cognitions about indirect aggression were mediators of indirect aggressive behavior. Finally, gender moderated the relations among the variables such that for girls, retaliation approval beliefs were a strong mediator, whereas for boys, self‐evaluation was more important. Aggr. Behav. 30:389–408, 2004. © 2004 Wiley‐Liss, Inc.     

Posttraumatic Stress Symptoms,Aggression, and Substance Use Coping among Young Adults

This study examined how the symptom clusters of posttraumatic stress disorder (PTSD) were related to substance use and self-reported aggression in a college sample. There were 358 participants (ages 18–24) who completed surveys to assess PTSD symptoms, substance use as coping, and aggression. Hierarchical regressions tested for the effects of PTSD symptoms (total symptoms as well as cluster symptoms) on self-reported aggression, along with the main and interaction effects of substance use coping on these relationships. The hyperarousal cluster of PTSD was the only group of symptoms significantly related to aggression. There was an interaction between avoidance symptoms and substance use coping on aggression such that under conditions of high substance use coping, aggression increased regardless of avoidance symptoms; however, the relationship between avoidance and aggression was stronger under conditions of low substance use coping, with greater aggression as avoidance symptoms and low substance use coping increased.     

The roles of trauma exposure,rejection sensitivity,and callous‐unemotional traits in the aggressive behavior of justice‐involved youth: A moderated mediation model

Research has demonstrated an association between childhood trauma exposure and adolescent aggression. This association may be explained by rejection sensitivity, defined as anger, or anxiety in the anticipation of rejection, which can be a consequence of trauma exposure. Callous‐unemotional (CU) traits also are associated with trauma exposure and aggressive behavior; however, research has not yet investigated the interactive roles that rejection sensitivity and CU traits play in the relation between trauma exposure and aggression. Therefore, this study sought to investigate the role of rejection sensitivity in the association between trauma exposure and aggression, and whether this indirect effect was moderated by CU traits. Participants included 380 detained youth (98 girls, 282 boys) who completed self‐report measures of trauma exposure, angry, and anxious rejection sensitivity, CU traits, and aggression. Results of moderated mediation demonstrated that the relation between trauma exposure and aggression exhibited an indirect effect through angry rejection sensitivity, but only at moderate or high levels of CU traits. This pattern was not found for anxious rejection sensitivity. Results suggest that interventions aimed to decrease aggressive behavior in traumatized adolescents may benefit from considering how youth respond to rejection, as well as whether youth endorse CU traits, as this may help to limit further involvement in the juvenile justice system after release.

     

Perceived Ability to Cope With Trauma Among U.S. Combat Veterans

The Perceived Ability to Cope With Trauma (PACT) scale measures perceived forward-focused and trauma-focused coping. This measure may also have significant utility measuring positive adaption to life-threatening trauma, such as combat. Our objective was to examine perceived ability to cope with trauma, as measured by the PACT, and the relationships between this perceived ability and clinically pertinent information (anxiety, depression, posttraumatic stress disorder [PTSD]) among U.S. military veterans. Data were provided from 71 combat veterans, consisting of 47 veterans with PTSD and 24 veterans without PTSD who had subthreshold symptoms of the disorder. All veterans completed standardized clinical interviews as well as a battery of well-validated self-report symptom measures. We found that veterans with PTSD had significantly lower PACT scores than veterans without PTSD; those without PTSD self-reported more ability to engage in forward-focused and trauma-focused coping than those with PTSD. Importantly, we also showed relationships between the PACT scores and indices of psychological difficulties as both Forward Focus and Trauma Focus coping scores negatively correlated with PTSD, depression, anxiety, and alexithymia. Finally, the Forward Focus PACT scale improved prediction of PTSD severity over combat exposure alone. The PACT, especially the Forward Focus scale, appears to be a useful measure of perceived positive coping ability with trauma in combat-exposed veterans who report symptoms of traumatic stress, extending the utility of the measure from normative to clinical populations. The importance of adopting forward-focused coping is discussed.     

Combat Exposure and Posttraumatic Stress Disorder Among Portuguese Special Operation Forces Deployed in Afghanistan

Several combat- and noncombat-related stressors have been reported in Afghanistan. There is now accumulating evidence that suggests that posttraumatic stress disorder (PTSD) is linked to combat experiences; however, little is known about how these exposures might affect elite combat troops. This research aims to evaluate the prevalence of combat and noncombat related stressors, as well as PTSD in Portuguese Special Forces deployed in Afghanistan. Overall, participants reported high levels of exposure to combat and adverse physical conditions but also high levels of within-unit comradeship. The analysis also exposed that 2.7% of the participants reported symptoms compatible with PTSD and 8.8% with compatible partial PTSD. When the authors conducted a binary logistic regression, only the higher levels of combat exposure explained the symptoms of PTSD.     

The effect of hardiness on PTSD symptoms: A prospective mediational approach

Psychological hardiness has been associated with lower PTSD in military personnel, but the processes of action remain unclear. This study uses a prospective design to examine whether hardiness has an indirect effect on PTSD symptoms through avoidance coping. Our sample included 163 Norwegian military personnel who served in international operations between 2009 and 2010. Regression analyses were performed to estimate the coefficients in a simple mediation model, with baseline PTSD symptoms, combat exposure, and deprivation of basic needs entered as control variables. The results showed that the effect of hardiness on PTSD symptoms worked through reducing the use of avoidance coping. It was concluded that an avoidant-focused coping style acts as a vulnerability factor for PTSD symptoms, whereas hardiness acts as a resilience factor against symptoms development.