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

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.     

The impact of intolerance of emotional distress and uncertainty on veterans with co-occurring PTSD and substance use disorders

The risk of developing a substance use disorder (SUD) is significantly higher among veterans with posttraumatic stress disorder (PTSD). Veterans with this co-occurrence have poorer outcomes than singly diagnosed veterans, which may be related to two risk factors: intolerance uncertainty (IU) and low tolerance of emotional distress (TED). We hypothesized low TED and high IU would independently and interactively relate to heightened PTSD symptomatology and trauma-cue elicited SUD cravings. A sample of 70 veterans (M age = 50; 95% men; 65% Black) with co-occurring PTSD-SUD was recruited. The Posttraumatic Stress Disorder Checklist (PCL), Craving Questionnaire, Distress Tolerance Scale, and Intolerance of Uncertainty Scale were administered. In general, low TED and high IU were significantly correlated with the PCL total and subscale scores. When examined within regression models, low TED was associated with elevated PCL scores and trauma-cue elicited SUD cravings; IU was not. However, there was a significant interaction between IU and TED; veterans with elevated IU and low TED had higher PCL Total, Hyperarousal, and Intrusions scores. This highlights the importance of assessing TED and IU among veterans with co-occurring PTSD-SUD, as these risk factors may not only be prognostic indicators of outcomes, but also treatment targets.     

Longitudinal relationships of insomnia,nightmares, and PTSD severity in recent combat veterans

Objective

This observational, longitudinal study of veterans with recent combat exposure describes the prevalence, severity and associations of posttraumatic stress disorder (PTSD), insomnia, and nightmares over time.

Methods

Eighty recent combat veterans recruited from Veterans Health Administration primary care settings met inclusion criteria including hazardous alcohol use and at least subthreshold PTSD. Insomnia status and nightmare status were assigned based on the Insomnia Severity Index total score and the PTSD Checklist nightmare item, respectively. Participants were re-assessed six months following their baseline assessment. Analyses of variance compared insomnia and nightmare groups on PTSD, depression, and alcohol use severity. Analyses of covariance (controlling for baseline differences) examined whether insomnia and/or nightmares were associated with the clinical course of PTSD. Persistence of conditions was also examined.

Results

At baseline, 74% presented with insomnia and 61% endorsed distressing nightmares. Insomnia was associated with significantly higher PTSD and depression severity at both baseline and six months. The presence of nightmares was associated with significantly higher PTSD severity at both time points and with depression severity at baseline only. Despite decreases in PTSD and depression severity, insomnia severity was relatively unchanged after six months. The prevalence and severity of nightmare complaints diminished modestly over time.

Conclusion

Among this sample of recent combat veterans, insomnia and nightmares were each strongly associated with the severity of both PTSD and depressive symptoms. Over time, insomnia in particular did not appear to resolve spontaneously and was associated with ongoing PTSD. Addressing insomnia early, therefore, may be a strategy to alter the course of PTSD.     

Pain intensity as a moderator of the association between opioid use and insomnia symptoms among adults with chronic pain

ObjectiveResearch documenting the impact of opioid use on sleep among individuals with chronic pain has been mixed. This study aimed to determine if pain intensity moderates the association between opioid use and insomnia symptoms among adults with comorbid symptoms of insomnia and chronic widespread pain.MethodsParticipants (N = 144; 95% female; mean age = 51.6, SD = 11.4) completed assessments of insomnia symptoms, pain and use of sleep/pain medication. Multiple regression was used to determine if pain intensity moderates the association between opioid use (yes/no) sleep onset latency (SOL), wake after sleep onset (WASO), sleep quality, or time in bed. Analyses controlled for gender, symptoms of sleep apnea, symptoms of depression, use of sleep medication (yes/no), and use of non-opioid pain medication (yes/no).ResultsStronger pain intensity was associated with longer self-reported WASO and worse sleep quality, independent of opioid use. Conversely, opioid use was associated with longer time in bed, independent of pain intensity. Opioid use and pain intensity interacted in the prediction of SOL, such that opioid use (vs. non-use) was associated with longer SOL in the context of mild but not moderate to severe pain intensity.ConclusionsOpioid use was associated with more difficulty falling asleep among adults with chronic pain; however, this cross-sectional effect was only significant among those reporting lower pain intensity. Authors speculate that this effect is masked among those with severe pain because the pain-related sleep debt they acquire throughout the night then facilitates sleep onset the next day.     

Adolescent peer aggression and its association with mental health and substance use in an Australian cohort

Prospective longitudinal birth cohort data was used to examine the association between peer aggression at 14 years and mental health and substance use at 17 years. A sample of 1590 participants from the Western Australian Pregnancy Cohort (Raine) study were divided into mutually exclusive categories (victims, perpetrators, victim-perpetrators and uninvolved). Involvement in any type of peer aggression as a victim (10.1%), perpetrator (21.4%), or a victim-perpetrator (8.7%) was reported by 40.2% of participants. After adjusting for confounding factors, those who were a victim of peer aggression had increased odds of later depression and internalising symptoms whilst perpetrators of peer aggression were found to be at increased risk of depression and harmful alcohol use. Victim-perpetrators of peer aggression were more likely to have externalising behaviours at 17 years. These results show an independent temporal relationship between peer aggression and later mental health and substance use problems in adolescence.     

Reciprocal longitudinal associations between substance use and child-to-parent violence in adolescents

Child-to-parent violence (CPV) is a type of violence that has received little attention despite its increasing rates in Western countries. Several models state that substance abuse constitutes a risk factor for aggressive behavior and that relationships among these variables can be reciprocal. In this study, the temporal relationships among substance use and physical and psychological CPV were examined. A sample of 981 adolescents (mean age = 15.22 years, SD = 1.2 years) completed measures of substance use and CPV at three time points (T1, T2, and T3) spaced 6 months apart. The results indicated that T1 levels of substance use predicted an increase in psychological CPV at T2 and that T2 levels of substance use predicted an increase in physical CPV at T3. Additionally, several mediational mechanisms emerged between substance use at T1 and CPV at T3. Neither physical nor psychological CPV predicted an increase in substance use at any time. Multiple comparisons indicated that the predictive association between substance use and physical aggression against parents was significant only in boys. These findings suggest that preventive programs for CPV should include specific components for reducing substance use.     

Associations among sleep problems, learning difficulties and substance use in adolescence

This study investigated the relationships among sleep problems, learning difficulties and substance use in adolescence. Previous research suggests that these variables share an association with executive functioning deficits, and are intertwined. The sample comprised 427 adolescents (M age = 16 years) attending remedial schools and 276 adolescents (M age = 15 years) attending a mainstream school in Cape Town, South Africa. Participants completed anonymous self-report questionnaires. Results indicated that adolescents without learning difficulties were more likely to use tobacco, methamphetamine and cannabis, whereas those with learning difficulties engaged in more inhalant use. Adolescents who had more sleep problems were more likely to use tobacco, alcohol, methamphetamine, cannabis, inhalants, cocaine, ecstasy and any other illegal drug. Adolescents with learning difficulties had more sleep problems than those without learning difficulties. However, sleep problems remained independently associated with tobacco, cannabis and inhalant use when learning difficulties were taken into account.     

Smoking,alcohol consumption,and drug use among adolescents with psychiatric disorders compared with a population based sample

This study investigated frequencies of smoking, alcohol use, and illicit drug use by diagnostic category in 566 adolescent psychiatric patients, comparing this sample with 8173 adolescents from the general population in Norway who completed the Young-HUNT 3 survey. Frequencies of current alcohol use were high in both samples but were lower among psychiatric patients. Compared with adolescents in the general population, adolescents in the clinical sample had a higher prevalence of current smoking and over four times higher odds of having tried illicit drugs. In the clinical sample, those with mood disorders reported the highest frequencies of smoking, alcohol use, and illicit drug use, whereas those with autism spectrum disorders reported the lowest frequencies. Our results show an increased prevalence of risky health behaviors among adolescents with psychiatric disorders compared with the general population. The awareness of disorder-specific patterns of smoking and substance use may guide preventive measures.     

Delay discounting and neurocognitive correlates among inner city adolescents with and without family history of substance use disorder

Adolescents with a family history (FH+) of substance use disorder (SUD) are at a greater risk for SUD, suggested to be partly due to the transmission of behavioral impulsivity. We used a delay discounting task to compare impulsivity in decision-making and its associated brain functioning among FH+ and FH - minority adolescents. Participants chose between Smaller Sooner (SS) and Larger Later (LL) rewards. The SS was available immediately (Now trials) or in the future (Not-Now trials), allowing for greater differentiation between impulsive decisions. The FH+ group showed greater impatience by responding SS more frequently than the FH - group, only on the Now trials, and even when the relative reward differences (RRD) increased. Surprisingly, there were no differences in brain activity between the groups. Combined, the groups showed greater reward activity during the Now vs. Not-Now trials in medial prefrontal/anterior cingulate, posterior cingulate, precuneus, and inferior frontal gyrus (i.e., an immediacy effect). As the RRD increased activation in the reward network decreased, including the striatum, possibly reflecting easy decision-making. These results indicate that risk for SUD, seen behaviorally among FH+ adolescents, may not yet be associated with discernable brain changes, suggesting that early intervention has the potential to reduce this risk.     

Substance use disorders: Relationship with intermittent explosive disorder and with aggression,anger, and impulsivity

BackgroundA relationship between substance use and aggression has been noted for decades. While substance use appears to be associated with an increased risk of aggressive behavior, no study has yet reported on the pattern of comorbidity and temporal relationship between impulsive aggression (i.e., intermittent explosive disorder) and substance use disorders (SUD), specifically.MethodsTo specify these relationships, we examined DSM-5 diagnosis data from diagnostic interviews of 1355 adults who met one of five non-overlapping diagnostic subgroups: those with intermittent explosive disorder (IED; n = 339), those with SUD (n = 136), IED+SUD (n = 280), adults with psychiatric disorders but no SUD or IED (n = 320), and healthy Controls: HC, n = 282).ResultsOccurrence of lifetime SUD was elevated in IED vs. all Non-IED subjects (Odds Ratio: 3.61 [95% CI: 2.82–4.63]) and onset of IED preceded SUD in 80% of comorbid IED+SUD cases. Examination of the severity of impulsive aggression and SUD revealed that IED increased SUD severity but the presence of SUD did not increase severity of IED core features, including aggression, anger, or impulsivity.ConclusionsSubjects with IED are at increased risk of developing substance use disorder, compared to those without IED. This suggests that history of recurrent, problematic, impulsive aggression is a risk factor for the later development of SUD rather than the reverse. Thus, effective treatment of impulsive aggression, before the onset of substance misuse, may prevent or delay the development of SUD in young individuals.     

Benzodiazepine use in posttraumatic stress disorder among veterans with substance abuse

Veterans with posttraumatic stress disorder (PTSD) and substance abuse may abuse benzodiazepines and develop violent dyscontrol when using them. A total of 370 veterans were compared by substance abuse diagnosis (50%), benzodiazepine use (36%), and their interaction on 1-year outcomes after inpatient discharge. Substance abusers were less likely to be prescribed benzodiazepines (26% vs. 45%). No outcome showed a differential worsening by substance abuse or benzodiazepines, although some baseline differences were noted. Outpatient health care utilization was lower in benzodiazepine users (47 vs. 33 visits). Among PTSD patients with comorbid substance abuse, benzodiazepine treatment was not associated with adverse effects on outcome, but it may reduce health care utilization.     

Problem alcohol use in veterans with mild traumatic brain injury: Associations with cognitive performance and psychiatric symptoms

Introduction: Given that little is known about the associations between alcohol use, cognition, and psychiatric symptoms among veterans with a history of mild traumatic brain injury (mTBI), we aimed to (a) characterize how they differ from veteran controls on a measure of problem drinking; (b) investigate whether problem drinking is associated with demographic or mTBI characteristics; and (c) examine the associations between alcohol use, mTBI history, psychiatric functioning, and cognition. Method: We assessed 59 veterans (n = 32 with mTBI history; n = 27 military controls) for problem alcohol use (Alcohol Use Disorders Identification Test: AUDIT), psychiatric symptoms, and neuropsychological functioning. Results: Compared to controls, veterans with mTBI history were more likely to score above the AUDIT cutoff score of 8 (p = .016), suggesting a higher rate of problem drinking. Participants with mTBI history also showed elevated psychiatric symptoms (ps < .001) and lower cognitive scores (ps < .05 to < .001). Veterans with higher AUDIT scores were younger (p = .05) and had less education (p < .01) and more psychiatric symptoms (ps < .01), but mTBI characteristics did not differ. After controlling for combat and mTBI history (R² = .04, ns) and posttraumatic stress disorder (PTSD) symptoms (ΔR² = .08, p = .05), we found that higher AUDIT scores were associated with poorer attention/processing speed, F(9, 37) = 2.55, p = .022; ΔR² = .26, p = .03. Conclusions: This preliminary study suggested that veterans with mTBI history may be at increased risk for problem drinking. Problem alcohol use was primarily associated with more severe PTSD symptoms and poorer attention/processing speed, though not with combat or mTBI characteristics per se. Importantly, findings emphasize the importance of assessing for and treating problematic alcohol use and comorbid psychiatric symptoms among veterans, including those with a history of neurotrauma.     

Association between anxiety disorders and substance use disorders among young persons: results of a 21-year longitudinal study

OBJECTIVE: To examine the linkages between anxiety disorders and the development of substance use disorders in a birth cohort of young people studied to young adulthood. METHOD: Data were gathered over the course of a longitudinal study of a birth cohort of over 1000 New Zealand born young people. Over the course of the study, data were gathered on: (a) anxiety disorders and substance use disorders at ages 16-18 and 18-21; (b) a range of potential confounding factors including measures of childhood, social, and family factors. RESULTS: Young people with anxiety disorders had odds of substance dependence that were between 1.3 and 3.9 times higher than young people without anxiety disorders. These associations were largely explained by a series of covariate factors relating to: (a) childhood and family factors; (b) prior substance dependence; (c) comorbid depression; (d) peer affiliations. After adjustment for these factors, anxiety disorder was unrelated to all measures of substance use. CONCLUSIONS: Young people with anxiety disorders are at increased risk of substance dependence. However, this association appears to be largely or wholly non causal and reflects the associations between childhood factors, prior substance dependence, comorbid depression, peer affiliations and the development of anxiety disorders.     

The risk of offspring developing substance use disorders when exposed to one versus two parent(s) with alcohol use disorder: A nationwide,register-based cohort study

AimFew population-based, family studies have examined associations between exposure to one vs. two parent(s) with alcohol use disorder (AUD) and the risk of offspring developing substance use disorder (SUD). Moreover, these studies have focused solely on the development of AUD, and not SUD, in offspring. The purpose of this study was to investigate whether exposure to one vs. two parent(s) with AUD increases the risk of offspring developing SUD.MethodsA population-based, cohort study was conducted in which offspring born in Denmark between 1983 and 1989 were followed through national registries until 2011. Register-based data were obtained from the: Psychiatric Central Research Register, National Patient Registry, Civil Registration System, Fertility Database, and Cause of Death Register. Adjusted hazard ratios were calculated using multivariate Cox-regression models.FindingsA total of 398,881 offspring were included in this study. Of these, 3.9% had at least one parent with AUD. Parental AUD was significantly associated with the development of SUD in offspring. Having one parent with AUD was linked to a 1.44-fold increased risk (95% CL, 1.29–1.61), while having two parents with AUD was linked to a 2.29-fold increased risk (95% CI, 1.64–3.20). No significant differences were found in relation to either parental or offspring gender.ConclusionsExposure to parental AUD is linked to an increased risk of offspring developing SUD. This risk is additive for offspring exposed to double parental AUD. The findings have important implications for clinical assessment and intervention strategies, as well as the management of offspring exposed to parental AUD.     

Social media use and risky behaviors in adolescents: A meta-analysis

IntroductionThis systematic review and meta-analysis examined the associations between social media use and risky behaviors during adolescence, and evaluated study characteristics (e.g., sample age, type of social media platform assessed) that may moderate these relationships.MethodsA comprehensive search strategy identified relevant studies from PsycInfo, PubMed, Google Scholar, and Proquest Dissertations and Theses Global.ResultsThe final sample included 27 independent cross-sectional studies with a total of 67,407 adolescents (M_age = 15.5, range: 12.6–18.0 years; 51.7% girls; 57.2% White). Results from random effects models indicated that there were positive, small-to-medium correlations between social media use and engagement in risky behaviors generally (r = 0.21, 95% CI = 0.16-0.25), substance use (r = 0.19, 95% CI = 0.12-0.26), and risky sexual behaviors (r = 0.21, 95% CI = 0.15-0.28). There were an insufficient number of independent samples available to conduct a random effect models for violence-related behaviors (k = 3). Moderator analyses suggested that studies assessing solely early social media platforms (e.g., Facebook/MySpace only) in relation to substance use had smaller effect sizes than substance use studies assessing a broader range of contemporary social media platforms. In addition, younger samples had larger effect sizes for studies focused on social media use and risky sexual behaviors.ConclusionsThe positive links identified between social media and risky behaviors during adolescence in this meta-analysis suggest that developmental theories of risk taking would benefit from incorporating the social media context. Longitudinal studies are needed to clarify directionality and make more specific practice and policy recommendations so that social media is a safe place in which adolescents can thrive.     

Neural cognitive control moderates the longitudinal link between hedonia and substance use across adolescence

Hedonic dysregulation is evident in addiction and substance use disorders, but it is not clearly understood how hedonic processes may interact with brain development related to cognitive control to influence risky decision making and substance use during adolescence. The present study used prospective longitudinal data to clarify the role of cognitive control in the link between hedonic experiences and the development of substance use during adolescence. Participants included 167 adolescents (53% male) assessed at four time points, annually. Adolescents participated in a functional magnetic resonance imaging (fMRI) session where blood-oxygen level dependent (BOLD) response was monitored during the Multi-Source- Interference Task to assess cognitive control. Substance use and hedonia were assessed using self-report. A two-group growth curve model of substance use with hedonia as a time-varying covariate indicated that higher levels of hedonia predicted higher substance use, but only in adolescents with higher activation in the frontoparietal regions and in the rostral anterior cingulate cortex during cognitive control. Results elucidate the moderating effects of neural cognitive control on associations between hedonia and adolescent substance use, suggesting that lower cognitive control functioning in the brain may exacerbate risk for substance use promoted by hedonia.     

Sex and substance use behaviors among children of teen mothers: A systematic review

IntroductionAdolescent birth is a known correlate of many challenging behavioral health consequences for offspring. This systematic review seeks to understanding the sex and substance use behaviors of children born to teen mothers extending the body of literature on the long-term outcomes of being born to a teen mother.MethodsA systematic approach, in accordance with PRISMA guidelines, was used to review and identify eligible studies in the following electronic databases: Web of Science, ProQuest, PubMed, and Ovid MEDLINE. Study inclusion: (a) maternal age (>20) was the key predictor or group variable and (b) children's risky sexual or substance use behaviors were outcome variables. All articles meeting inclusion criteria were next screened using the quality assessment tool created by the Effective Public Health Practice Project.ResultsSeventeen articles reporting on risky sexual behaviors and 12 articles on substance use behaviors met inclusion criteria. We found a consistent association between being born to a teen mother and risky sexual behaviors, including early sexual debut and transitioning into motherhood during adolescence/young adulthood. The link between being born to a teen mother and substance use behaviors was inconsistent and only found in large population-based studies.ConclusionTeen mothers and their children have unique individual, family, and structural needs. Evidence highlights that while there is no clear need to adapt substance use prevention interventions for these children, investing in targeted adaptations of abstinence and safer sex interventions to meet the unique experiences of children of teen mothers and their children is warranted.     

Neurocognition and inhibitory control in polysubstance use disorders: Comparison with alcohol use disorders and changes with abstinence

Introduction: Intact neurocognition and early cognitive recovery during abstinence are important for substance use treatment outcome. Yet, little is known about them in the largest group of treatment seekers today, individuals with polysubstance use disorders (PSU). This study primarily contrasted PSU and individuals with an alcohol use disorder (AUD) on neurocognitive and inhibitory control measures and, secondarily, measured changes during abstinence in PSU. Method: At one month of abstinence from all substances except tobacco, 36 PSU and 69 AUD completed neurocognitive assessments of executive function, general intelligence, auditory–verbal learning/memory, visuospatial learning/memory/skills, processing speed, working memory, fine motor skills, and cognitive efficiency. The groups were also assessed on inhibitory control measures of self-reported impulsivity, risk-taking, and decision-making. Seventeen PSU repeated the assessments after approximately four months of abstinence. All cross-sectional and longitudinal analyses included smoking status as a possible confound. Results: At baseline, PSU performed significantly worse than AUD on auditory–verbal memory and on an inhibitory control measure of impulsivity. Polysubstance users showed trends to worse performance than AUD on general intelligence, auditory–verbal learning, and a decision-making task. Between one and four months of abstinence, PSU showed significant improvements on several neurocognitive and inhibitory control measures. Conclusions: Polysubstance users exhibit distinct differences in neurocognition and inhibitory control compared to AUD. Between one and four months of abstinence, neurocognition and inhibitory control improve in PSU. This neurocognitive recovery in some domains of abstinent PSU is influenced by smoking status. These results underscore the clinical value of select methods to augment neurocognitive recovery in PSU through appropriate interventions.     

Sex differences and eating disorder risk among psychiatric conditions,compulsive behaviors and substance use in a screened Canadian national sample

Objective

This study examined sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors (i.e., gambling, suicide thoughts and attempts) and substance use in a nationally representative sample.

Method

Data from participants of the Canadian Community Health Survey Cycle 1.2 who completed the Eating Attitudes Test (n= 5116) were analyzed. Sex differences were compared among psychiatric comorbidities according to eating disorder risk, binging, vomiting and dieting behavior. Poisson regression analysis provided prevalence ratios (PRs) of disordered eating adjusting for age, marital status, income, body mass index and recent distress.

Results

Pronounced sex differences were associated with eating disorder risk (PRs 4.89–11.04; all P values < .0001). Findings of particular interest included significantly higher PRs for eating disorder risk in males associated with gambling (PR 5.07, P< .0001) and for females associated with steroid and inhalant use as well as suicide thoughts and attempts (PRs 5.40–5.48, all P values < .0001).

Discussion

The findings from this detailed exploration of sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use suggest that problem gambling, the use of inhalants and steroids and suicidal ideation in relationship to eating disorder risk warrant further investigation.