Associations between substance use, post-traumatic stress disorder and the perpetration of violence: A longitudinal investigation

Recovery Horizons: Nature-Based Activities as Adjunctive Treatments for Co-Occurring Post-Traumatic Stress Disorder and Substance Use Disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) frequently co-occur, and individuals with co-occurring PTSD and SUD often experience more complex treatment challenges and poorer outcomes compared to those with either condition alone. Integrative treatment approaches that simultaneously address both PTSD and SUD are considered the most effective and include both pharmacological and non-pharmacological strategies. In recent years, complementary interventions have garnered increased attention due to their broad appeal and potential therapeutic benefits in enhancing existing treatments for PTSD and SUD. This review explores the existing literature on the use of nature-based activities, such as hiking, camping, sailing, and surfing in treating individuals with co-occurring PTSD and SUD. Nature-based activities offer promising adjunctive benefits, including the reduction of PTSD symptoms and craving levels. While evidence supports the therapeutic value of nature-based activities, current research remains limited. Further research is needed to better understand their therapeutic role and to refine their implementation in clinical practice.

The Role of Gut Microbiome in Sleep Quality and Health: Dietary Strategies for Microbiota Support

Dietary components, including dietary fiber, unsaturated fatty acids, and polyphenols, along with meal timing and spacing, significantly affect the microbiota's capacity to produce various metabolites essential for quality sleep and overall health. This review explores the role of gut microbiota in regulating sleep through various metabolites such as short-chain fatty acids, tryptophan, serotonin, melatonin, and gamma-aminobutyric acid. A balanced diet rich in plant-based foods enhances the production of these sleep-regulating metabolites, potentially benefiting overall health. This review aims to investigate how dietary habits affect gut microbiota composition, the metabolites it produces, and the subsequent impact on sleep quality and related health conditions.

A longitudinal mediational investigation of risk pathways among cannabis use, interpersonal trauma exposure, and trauma-related distress

OBJECTIVE

College students are at high risk for cannabis use, interpersonal trauma (IPT) exposure, and trauma-related distress (TRD). Two phenotypic etiologic models posited to explain associations between cannabis use and trauma-related phenotypes are the self-medication (trauma/TRD → cannabis use) and high-risk (cannabis use → trauma/TRD) hypotheses. The primary objective of the present study was to investigate direct and indirect associations among cannabis use, IPT exposure, and TRD above and beyond established covariates.

METHOD

The current study used data from the first assessment (i.e., baseline survey at Year 1 Fall) and two follow-up assessments (i.e., Year 1 Spring and Year 2 Spring) from an ongoing longitudinal study on college behavioral health. Participants were 4 cohorts of college students (n = 9,889) who completed measures of demographics, substance use, IPT, and TRD. Indirect effects of IPT on cannabis through TRD (i.e., self-medication) and cannabis on TRD through IPT (i.e., high-risk), including tests of covariate effects (e.g., gender, age, race, cohort, alcohol, nicotine), were simultaneously estimated using a longitudinal mediation modeling framework.

RESULTS

Results suggest that more IPT exposure increases risk for TRD and subsequent nonexperimental (use 6+ times) cannabis use, and that experimental (use 1-5 times) and nonexperimental cannabis use increases risk for IPT exposure and subsequent TRD.

CONCLUSIONS

Both the self-medication and high-risk hypotheses were supported. Findings support a bidirectional causal relationship between cannabis use and trauma-related phenotypes. Additionally, results highlight areas for colleges to intervene among students to help reduce cannabis use and create a safer environment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Antecedents of sibling aggression and bullying victimization: The parallel and serial contributions of depressive symptoms and substance use

PURPOSE

Sibling aggression has received attention as a common form of family violence. However, further research is needed to elucidate several antecedents of sibling aggression perpetration and bullying victimization, such as substance use and depressive symptoms. Additionally, more studies are needed to identify the mediating paths of depressive symptoms and substance use, which could explain the association between bullying victimization and sibling aggression perpetration on the one hand and the association between sibling aggression victimization and bullying victimization on the other hand, while controlling for exposure to family violence and demographic variables. The current study tested two separate mediational models guided by the displaced aggression theory and self-medication hypothesis.

METHOD

The present study used the Bullying, Sexual, and Dating Violence Trajectories From Early to Late Adolescence in the Midwestern United States, 2007-2013 dataset. The original sample consisted of 1162 middle school students who were initially surveyed and followed into three high schools. For the current study, the first wave was used, which included a sample of 1101 adolescents. Structural equation modeling (SEM) was conducted to first examine whether bullying victimization was associated with sibling aggression perpetration. Then another model was conducted to test whether sibling aggression victimization was associated with bullying victimization.

RESULTS

In the first model, results suggest bullying victimization is positively associated with sibling aggression. Mediation results indicated depressive symptoms and substance use serially mediated the relation between bullying victimization and sibling aggression. In the second model, results suggest that sibling aggression victimization is positively associated with bullying victimization. Parallel mediation results indicated that depressive symptoms alone and not substance use individually explained the association between sibling aggression victimization and bullying victimization. Finally, serial mediation results indicated that depressive symptoms and substance use serially mediate the association between sibling aggression victimization and bullying victimization.

LIMITATIONS

Limitations include self-report measures and cross-sectional design; therefore, we could not estimate casual relationships.

CONCLUSION

The implications of these findings suggest the need for continued attention to school-based bully prevention efforts and family relations interventions. Such efforts might be associated with reductions in bullying victimization and sibling aggression.

When State Violence Comes Home: From Criminal Legal System Exposure to Intimate Partner Violence in a Time of Mass Incarceration

Exceptionally high rates of partner violence perpetration are evident among men returning from prison. Two bodies of scholarship, one on family stress and another on exposure to state violence, each suggest that criminal legal system exposure could promote partner violence perpetration via changes in men's behavioral health and interpersonal approach and in couples' conflict dynamics. Such relationships have not been tested in quantitative research. Structural equation models were fitted to longitudinal, couples-based survey data from the Multi-site Family Study on Incarceration, Parenting, and Partnering. Participants included men returning from a state prison term in five U.S. states (N = 1112) and their committed intimate or co-parenting partners (N = 1112). Models tested hypothesized pathways from three dimensions of criminal legal system exposure to later partner violence perpetration. In fitted models, men's childhood criminal legal system exposure predicts their post-prison partner violence perpetration via adult post-traumatic stress symptoms, reactivity, avoidance, and dysfunctional couple conflict dynamics. Men's cumulative criminal legal system exposure in adulthood predicts their post-prison partner violence perpetration via addiction and dysfunctional couple conflict. These initial results suggest that mass-scale incarceration could worsen partner violence via men's psychological and interpersonal adaptations to criminal legal system contact, particularly when such contact is sustained or occurs at a developmentally significant period in the life course.

Violence - suicide and suicidal ideation as sequelae of trauma in substance use disorder inpatients

Experience with psychological trauma is overrepresented among substance use disorder (SUD) patients. SUDs may also be a risk factor for violent behaviors, suicidal ideation and suicide. This study proposes a link between these phenomena. Based on data from the EuropASI clinical interview of 137 SUD inpatients we computed a composite variable of trauma experience from being abused. We report descriptive data and cross tabulated problems controlling violent behavior, suicidal ideation or suicide attempts variables with trauma experience. Hypothesizing an association between experienced trauma and the outcome variables. We also examined the correlation between three outcome variables in inpatients. Our data suggested high incidents of experienced psychological trauma in the sample (66.7%). Chi-square tests suggested a significant difference in controlling violent behavior, suicidal ideation and suicide attempts, dependent on trauma experience. Spearman Roh correlations suggested asscociations between suicdal ideation and suicide attempts, and suicdal ideation and problems controlling violent behavior, but not with suicide attempts. Our data suggests that past trauma is a risk factor for violent and suicidal behaviors in the SUD population. Based on our findings we propose that former trauma should be considered in risk assessments and help guide treatment interventions.

Comparative effectiveness of trauma-focused and non-trauma-focused psychotherapy for PTSD among veterans with comorbid substance use disorders: Protocol & rationale for a randomized clinical trial

BACKGROUND

Co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is common and concurrent treatment is recommended. Relatively little is known about which evidence-based psychotherapies for PTSD are most effective for patients with varying substance use profiles. We aim to examine the comparative effectiveness of trauma-focused therapy (TFT) and non-trauma-focused therapy (NTFT) among Veterans with PTSD and SUD. TFT has been found to be effective among those with PTSD/SUD, though effects are smaller and rates of treatment non-completion are higher than in those without SUD. NTFTs suggested for the treatment of PTSD, such as Present Centered Therapy, (PCT) have not been examined among those with co-occurring SUD, despite lower rates of treatment dropout. We will also examine the comparative effectiveness of TFT and NTFT for patients with varying SUD severity, type of substances used, and patient treatment preference.

METHOD

420 Veterans with PTSD and SUD will be randomized in a prospective, pragmatic comparative effectiveness trial at 14 Veterans Health Administration facilities. Participants will receive either TFT (Prolonged Exposure or Cognitive Processing Therapy) or NTFT (PCT) after enrolling in concurrent SUD treatment-as-usual. Assessments will occur at baseline, posttreatment, 3- and 6 -months posttreatment. Main outcomes are PTSD symptom severity and PTSD treatment dropout. Clinician, patient, and leadership stakeholder panels advise study activities, and a process evaluation will identify strategies to enhance the implementation of evidence-based PTSD treatments in SUD care settings.

CONCLUSIONS

Results will provide critical information to guide clinicians when recommending PTSD treatments to patients with comorbid SUD.

CLINICALTRIALS

gov Identifier: NCT04581434.

Trauma and aggression: Evaluating the influence of primed hostility and survivor sex

OBJECTIVES

The relation between posttrauma symptoms and aggression is an area of growing interest in the larger clinical literature. The current project looked to examine the impact of primed hostility on aggressive responding in men and women with and without a history of prior trauma.

DESIGN

Experimental aggression paradigm assessed in a 2 (Group) × 2 (Sex) × 2 (Prime) mixed factorial ANOVA.

METHODS

Trauma-naïve participants (N = 52) and survivors reporting active symptoms (N = 43) were exposed to hostile and neutral lexical primes in what was presented as a reaction time task played against an unseen 'opponent'. In actuality, 'wins' and 'losses' during the task were assigned by an automated system. The intensity of an aversive sound blast delivered by participants to the supposed opponent in trials the participant 'won' served as an index of behavioural aggression.

RESULTS

Repeated-measures ANOVA identified a between-by-within interaction of exposure group and lexical prime (p = .010; η p 2 $$ {\eta}_p^2 $$  = .070), with trauma-exposed participants (p = .002, Δ = .30), but not controls (p = .159, Δ = .11), demonstrating elevations in aggression subsequent to hostile priming. A sex by prime interaction (p = .001; η p 2 $$ {\eta}_p^2 $$  = .117) similarly indicated elevated aggression following hostile priming in men (p = .007, Δ = .58) as compared to women (p = .062, Δ = .10).

CONCLUSIONS

Results offer preliminary support for the association of situationally primed hostility and biological sex with aggressive responding in survivors reporting active symptoms.

Examining Associations between Adverse Childhood Experiences and Posttraumatic Stress Disorder Symptoms among Young Survivors of Urban Violence

Our study examines the association between Adverse Childhood Experience (ACE) exposure and posttraumatic stress disorder (PTSD) symptoms among survivors of violence. In this cross-sectional study, an ACE questionnaire and PTSD Checklist for DSM-5 (PCL-5) were completed by 147 participants ≤ 3 months after presenting to a Philadelphia, PA emergency department between 2014 and 2019 with a violent injury. This study treated ACEs, both separate and cumulative, as exposures and PTSD symptom severity as the outcome. Most participants (63.3%) met criteria for provisional PTSD, 90% reported experiencing ≥ 1 ACE, and 39% reported experiencing ≥ 6 ACEs. Specific ACEs were associated with increasing PCL-5 scores and increased risk for provisional PTSD. Additionally, as participants' cumulative ACE scores increased, their PCL-5 scores worsened (b = 0.16; p < 0.05), and incremental ACE score increases predicted increased odds for a positive provisional PTSD screen. Results provide further evidence that ACEs exacerbate the development of PTSD in young survivors of violence. Future research should explore targeted interventions to treat PTSD among survivors of interpersonal violence.

Imaginal exposure processing during Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) therapy: Examination of linguistic markers of cohesiveness

Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) is an integrated, evidence-based treatment that results in significant reductions in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) severity. Emotional processing theory suggests that successful prolonged exposure-based treatments should result in more cohesive trauma narratives due to better integration and organization of trauma memory into cognitive conceptualizations of fear. Therefore, we hypothesized that language used by patients would become more cohesive over time and increased language cohesion would be related to larger reductions in PTSD and SUD outcomes. Broadly, language cohesion refers to several linguistic devices that help establish and cohere meaning throughout spoken and written discourse (e.g., increased use of transition words like "and," "then," and "but"). This was the first known study to examine changes in language related to both PTSD and SUD severity during COPE treatment. The sample included 28 military veterans with current comorbid PTSD/SUD enrolled in a larger COPE study. A text analysis program, Coh-Metrix, was used to analyze language cohesiveness. No language cohesion variables significantly changed over time. Narrativity levels significantly moderated change in PTSD outcomes, R β 2 $R_\beta ^2\;$ = 0.11. Adversative connectives significantly moderated change in SUD outcomes, R β 2 $R_\beta ^2\;$ = 0.26. The findings illuminate potential processes underlying successful COPE treatment. Less use of language conveying a narrative and more use of contrast-indicative words (e.g., but, whereas) was associated with larger reductions in PTSD and SUD outcomes during treatment. These results contribute to the extant literature on associations between trauma exposure, language, and emotional processing.

A Prospective US National Trauma Center Study of Firearm Injury Survivors Weapon Carriage and Posttraumatic Stress Disorder Symptoms

OBJECTIVE

To describe the demographic, injury-related, and mental health characteristics of firearm injury patients and trace firearm weapon carriage and PTSD symptoms over the year after injury.

SUMMARY AND BACKGROUND DATA

Based on the increasing incidence of firearm injury and need for novel injury prevention strategies, hospital-based violence intervention programs are being implemented in US trauma centers. There is limited data on the long-term outcomes and risk behaviors of firearm injury survivors to guide this work.

METHODS

We conducted a secondary analysis of a pragmatic 25-trauma center randomized trial (N = 635). Baseline characteristics of firearm-injured patients (N = 128) were compared with other trauma patients. Mixed model regression was used to identify risk factors for postinjury firearm weapon carriage and PTSD symptoms.

RESULTS

Firearm injury patients were younger and more likely to be black, male and of lower socioeconomic status, and more likely to carry a firearm in the year before injury. Relative to preinjury, there was a significant drop in firearm weapon carriage at 3- and 6-months postinjury, followed by a return to preinjury levels at 12-months. Firearm injury was significantly and independently associated with an increased risk of postinjury firearm weapon carriage [relative risk = 2.08, 95% confidence interval (1.34, 3.22), P < 0.01] and higher PTSD symptom levels [Beta = 3.82, 95% confidence interval (1.29, 6.35), P < 0.01].

CONCLUSIONS

Firearm injury survivors are at risk for firearm carriage and high PTSD symptom levels postinjury. The significant decrease in the high-risk behavior of firearm weapon carriage at 3-6 months postinjury suggests that there is an important postinjury "teachable moment" that should be targeted with preventive interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02655354.

Community Violence, PTSD, Hopelessness, Substance Use, and Perpetuation of Violence in an Urban Environment

We investigated the relationships among chronic violence exposure, post-traumatic stress disorder (PTSD) symptom severity, hopelessness, substance use, and perpetuation of violence to facilitate the development of trauma-related interventions for residents of Newark, NJ. A convenience sample of Newark residents (N = 153) was recruited from community centers during various events in 2016-2017. Anonymous, self-report survey measures included a PTSD screen (PCL-C), Beck's Hopelessness Scale, the CAGE questionnaire, and a CDC Health Behavior Scale. Descriptive statistics, Pearson's correlations, Chi square analyses, logistic, and linear regressions were used for analysis. Thirty percent (95% CI [22.7, 37.4]) of our sample screened positive for PTSD. Drug and alcohol use, fighting, and hopelessness were related to severity of PTSD symptoms (p < 0.05). Female gender, CAGE scores, and hopelessness predicted the severity of PTSD symptoms (R² = 0.354, p < 0.05). Our data has informed the development of a resilience support group currently in the pilot stage for community members.

Problematic Use of the Internet in Subjects With Bipolar Disorder: Relationship With Posttraumatic Stress Symptoms

Background: Literature shows a high risk for problematic use of the Internet (PUI) in mood disorders, especially in bipolar disorder (BD). In subjects with BD, traumatic events and posttraumatic stress disorder (PTSD) are related to alcohol or substance use disorder, as well as to gambling disorder. However, little is known about the possible association between traumatic exposure and PUI. The present study was aimed at examining the relationship between PUI and trauma exposure, besides PTSD symptoms, in subjects with BD. Methods: A sample of 113 subjects with BD was screened to putative PUI. Furthermore, they completed the Trauma and Loss Spectrum Self-Report (TALS-SR) to assess traumatic events and posttraumatic stress symptoms. Results: Twenty-four subjects (21.2%) reported putative PUI. Subjects with putative PUI presented significantly higher scores in the TALS-SR domains Potentially Traumatic Events, Re-experiencing, Maladaptive coping, and Arousal, as well as in the TALS-SR total score. In a logistic regression model, a positive association emerged between Potentially Traumatic Events and Arousal TALS-SR domains and putative PUI. Conclusion: One in five patients with BD screened positive for PUI. A significant association between PUI and lifetime traumatic events as well as PTSD symptoms emerged, highlighting the relevance of the comorbidity between PTSD and PUI in subjects with BD.

Sleep and Microbiome in Psychiatric Diseases

Objectives: Disturbances in the gut–brain barrier play an essential role in the development of mental disorders. There is considerable evidence showing that the gut microbiome not only affects digestive, metabolic and immune functions of the host but also regulates host sleep and mental states through the microbiota–gut–brain axis. The present review summarizes the role of the gut microbiome in the context of circadian rhythms, nutrition and sleep in psychiatric disorders. Methods: A PubMed search (studies published between April 2015–April 2020) was conducted with the keywords: “sleep, microbiome and psychiatry”; “sleep, microbiome and depression”; “sleep, microbiome and bipolar disorder”, “sleep, microbiome and schizophrenia”, “sleep, microbiome and anorexia nervosa”, “sleep, microbiome and substance use disorder”, “sleep, microbiome and anxiety”; “clock gene expression and microbiome”, “clock gene expression and nutrition”. Only studies investigating the relationship between sleep and microbiome in psychiatric patients were included in the review. Results: Search results yielded two cross-sectional studies analyzing sleep and gut microbiome in 154 individuals with bipolar disorder and one interventional study analyzing the effect of fecal microbiota transplantation in 17 individuals with irritable bowel syndrome on sleep. In patients with bipolar disorder, Faecalibacterium was significantly associated with improved sleep quality scores and a significant correlation between Lactobacillus counts and sleep. Conclusion: Translational research on this important field is limited and further investigation of the bidirectional pathways on sleep and the gut microbiome in mood disorders is warranted.

Exploring Bullying Perpetration and Victimization Among Adolescent Girls in the Child Welfare System: Bully-Only, Victim-Only, Bully-Victim, and Noninvolved Roles

Childhood abuse is a common experience for youth in the child welfare system, increasing their risk of bullying perpetration and victimization. Little research exists that has examined the rates of bullying perpetration and victimization for child welfare-involved adolescent girls. The study addressed the following aims: (a) to generate frequency estimates of physical, nonphysical, and relational forms of bullying perpetration and victimization; (b) to identify the frequency of bully-only, victim-only, bully-victim, and noninvolved roles; and (c) to identify risk and protective factors that correlate with these bullying role types. Participants were 236 girls (12-19 years) in the child welfare system from a Midwestern urban area. Participants were referred to the study to join a trauma-focused group program. Seventy-five percent of the total sample were youth of color, with the remaining 25% identifying as White, non-Hispanic. Data were collected through baseline surveys that assessed childhood abuse, bullying perpetration and victimization, posttraumatic stress, substance misuse, aggression-related beliefs and self-efficacy, placement type, placement instability, and mental health service use. Child welfare-involved adolescent girls were found to assume all four major role types: bully-only (6.4%, n = 15), victim-only (20.3%, n = 48), bully-victim (44.1%, n = 104), and nonvictims (29.2%, n = 69). The bully-victim rate was approximately 7 times higher than the rate found in a nationally representative sample of non-child welfare-involved youth. The current study identified posttraumatic stress disorder (PTSD) symptoms, anger self-efficacy, and alcohol use as significant correlates of bullying roles. The identification of a substantially higher rate of bully-victims has important practice implications, suggesting child welfare and school systems adopt trauma-informed systems of care. Bully-victims are very likely traumatized children who are in need of effective trauma treatment rather than punitive sanctions.

Holistic Conceptualizations of Health by Incarcerated Aboriginal Women in New South Wales, Australia

While there has been extensive research on the health and social and emotional well-being (SEWB) of Aboriginal women in prison, there are few qualitative studies where incarcerated Aboriginal women have been directly asked about their health, SEWB, and health care experiences. Using an Indigenous research methodology and SEWB framework, this article presents the findings of 43 interviews with incarcerated Aboriginal women in New South Wales, Australia. Drawing on the interviews, we found that Aboriginal women have holistic conceptualizations of their health and SEWB that intersect with the SEWB of family and community. Women experience clusters of health problems that intersect with intergenerational trauma, perpetuated and compounded by ongoing colonial trauma including removal of children. Women are pro-active about their health but encounter numerous challenges in accessing appropriate health care. These rarely explored perspectives can inform a reframing of health and social support needs of incarcerated Aboriginal women establishing pathways for healing.

Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans

OBJECTIVE

A substantial amount of individuals with substance use disorders (SUD) also meet criteria for posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) is an effective, evidence-based treatment for PTSD, but there is limited data on its use among individuals with current alcohol or drug use disorders. This study evaluated the efficacy of an integrated treatment that incorporates PE (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure or COPE) among veterans.

METHOD

Military veterans (N = 81, 90.1% male) with current SUD and PTSD were randomized to 12 sessions of COPE or Relapse Prevention (RP). Primary outcomes included the Clinician Administered PTSD Scale (CAPS), PTSD Checklist-Military version (PCL-M), and the Timeline Follow-back (TLFB).

RESULTS

On average, participants attended 8 out of 12 sessions and there were no group differences in retention. Intent-to-treat analyses revealed that COPE, in comparison to RP, resulted in significantly greater reductions in CAPS (d = 1.4, p < .001) and PCL-M scores (d = 1.3, p = .01), as well as higher rates of PTSD diagnostic remission (OR = 5.3, p < .01). Both groups evidenced significant and comparable reductions in SUD severity during treatment. At 6-months follow-up, participants in COPE evidenced significantly fewer drinks per drinking day than participants in RP (p = .05).

CONCLUSIONS

This study is the first to report on the use of an integrated, exposure-based treatment for co-occurring SUD and PTSD in a veteran sample. The findings demonstrate that integrated, exposure-based treatments are feasible and effective for military veterans with SUD and PTSD. Implications for clinical practice are discussed.

Alcohol use moderates the relationship between symptoms of mental illness and aggression

Diagnosis of mental illness (MI) inconsistently predicts aggressive behavior although co-occurrence of substance use appears to increase the frequency of aggression in MI populations. We propose that alcohol use should moderate the relationship between mental disorders marked by deficits in self-control and aggression and victimization. In the present study, alcohol use, physical aggression perpetration, physical aggression victimization, injury and psychiatric symptoms were assessed in a sample of 297 substance use disorder patients (102 women; M_age = 38.9, SD = 20.2) recruited from a residential treatment facility. Negative binomial regression analyses examined the relationship of physical aggression, victimization, and injury over the previous 12 months to symptoms of bipolar mania, psychosis, posttraumatic stress disorder, antisocial personality disorder (ASPD), and daily volume of alcohol consumed. Consistent with past research relating MI to aggression, rates of victimization were higher than rates of perpetration. Results demonstrated that alcohol use moderated the relationship of manic symptoms of bipolar disorder to perpetration of aggression and causing injury to others. Three way-interactions between gender, alcohol use, and both psychotic and ASPD symptoms were related to victimization. The combination of heavy alcohol use and increased psychotic or ASPD symptoms was related to greater victimization for women but not for men. Women with more psychotic symptoms who were heavy drinkers were also more likely to report causing injury to another person. Results were generally consistent with the multiple-thresholds model of alcohol-related aggression; however, the moderating effects of alcohol use were dependent on gender and type MI. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A Randomized Controlled Trial for Veterans with PTSD and Substance Use Disorder: Creating Change versus Seeking Safety

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) co-occur in military veterans and other populations.

OBJECTIVE

To conduct a randomized controlled trial to compare a new past-focused treatment (Creating Change; CC), to a well-established, evidence-based present-focused treatment for PTSD/SUD (Seeking Safety; SS), on symptoms of both disorders. CC guides patients to process the past through exploration of PTSD/SUD life themes and memories whereas SS focuses on coping skills in the present.

METHODS

Fifty-two male and female veterans with current PTSD/SUD were randomized (n = 26 per treatment) and assessed at baseline, end-of-treatment and 3-month follow-up. They received 17 individual one-hour sessions.

RESULTS

Intent-to-treat analyses indicated that both conditions improved over time, with no difference between conditions, on PTSD, alcohol use, and drug use (our primary outcomes) as well as mental health symptoms, quality of life, self-efficacy, and SUD cognitions. Effect sizes were medium except for alcohol use, which was large. Change over time reflected improvement from baseline to end-of-treatment, with gains sustained at follow-up, although alcohol use showed continued improvement from end-of-treatment to follow-up. Both treatments evidenced a strong safety profile; and attendance, alliance, and treatment satisfaction were also very strong. Conclusions/importance: CC has promise as a PTSD/SUD therapy with strong public health relevance and the potential to fill important gaps in the field. We used minimal exclusionary criteria to obtain a real-world sample, which was severe-predominantly substance-dependent with chronic PTSD and additional psychiatric diagnoses. Future research is warranted, especially on nonveteran samples and treatment mechanisms of action.

Food addiction and substance addiction in women: Common clinical characteristics

Food addiction is characterized by poorly controlled intake of highly-palatable, calorically-dense, foods. While previous studies indicate that risk factors for food addiction are similar to substance use disorders (SUD), these studies have looked at food addiction and SUD in independent samples, limiting the ability to directly compare food addiction to SUD. The present study was conducted to assess rates of posttraumatic stress disorder (PTSD), depression, childhood and adult trauma exposure, as well as presence and severity of emotion dysregulation, in a sample of women (N = 229) who either meet criteria for no addiction, food addiction only or SUD only. The prevalence of food addiction was 18.3% and the prevalence of SUD was 30.6% in this sample. Women with food addiction and women with SUD endorsed more depression and PTSD symptoms when compared with individuals with no addiction. Individuals with food addiction and SUD had higher total emotion dysregulation scores, specifically with difficulties in goal directed behaviors, non-acceptance of emotional responses, impulse control, limited access to emotion regulation strategies, and lack of emotional clarity, when compared to individuals with no addiction (all p's < 0.05). There were no differences in PTSD and depression symptoms and emotion dysregulation scores between food addiction and SUD groups (all p > 0.05). However, women with SUD endorsed higher levels of total childhood (p < 0.01) and adulthood trauma (p < 0.01) as compared with women with no addiction or food addiction. These results suggest that women with food addiction and those with SUD share similar psychological characteristics and risk factors, with the exception of trauma histories. These findings have implications for the detection of risk for and treatment of these disorders.

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.

Trauma exposure and PTSD symptoms associate with violence in inner city civilians

Understanding whether a history of psychological trauma is associated with perpetrating aggressive and violent behavior is of critical importance to public health. This relationship is especially important to study within urban areas where violence is prevalent. In this paper we examined whether a history of trauma or Post Traumatic Stress Disorder (PTSD) in inner city civilians was associated with violent behavior. Data were collected from over 1900 primary care patients at Grady Memorial Hospital in Atlanta, Georgia. Childhood trauma history was assessed with the Childhood Trauma Questionnaire (CTQ) and adult trauma history with the Traumatic Events Inventory (TEI). PTSD symptoms were measured with the PTSD Symptom Scale (PSS) and violent behaviors were measured with the Behavior Questionnaire (BQ). Using these measures we studied violent behavior in the inner city and its association with childhood or adult trauma history or PTSD. Trauma, PTSD and violence were all prevalent in this at-risk urban cohort. Perpetrating interpersonal violence was associated with a history childhood and adult trauma history, and with PTSD symptoms and diagnosis. An association between violent behavior and PTSD diagnosis was maintained after controlling for other pertinent variables such as demographics and presence of depression. Our findings point to a dysregulation of aggressive and violent behavior that may be a consequence of trauma and PTSD. These data indicate that more effective PTSD screening and treatment may help to reduce urban violence.

Substance use modulates stress reactivity: Behavioral and physiological outcomes

Drug addiction is a major public health concern in the United States costing taxpayers billions in health care costs, lost productivity and law enforcement. However, the availability of effective treatment options remains limited. The development of novel therapeutics will not be possible without a better understanding of the addicted brain. Studies in both clinical and preclinical models indicate that chronic drug use leads to alterations in the body and brain's response to stress. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis may shed light on the ability of stress to increase vulnerability to relapse. Further, within both the HPA axis and limbic brain regions, corticotropin-releasing factor (CRF) is critically involved in the brain's response to stress. Alterations in both central and peripheral CRF activity seen following chronic drug use provide a mechanism by which substance use can alter stress reactivity, thus mediating addictive phenotypes. While many reviews have focused on how stress alters drug-mediated changes in physiology and behavior, the goal of this review is to focus on how substance use alters responses to stress.

Posttraumatic Stress Disorder, Hostile Cognitions and Aggression in Iraq/Afghanistan Era Veterans

OBJECTIVE

Most veterans with posttraumatic stress disorder (PTSD) are not violent, yet research has demonstrated that there is a substantial minority who are at increased risk. This study tested hypotheses regarding hyperarousal symptoms and hostile cognitions (i.e., "hostility") as potential mechanisms of the association between PTSD and physical aggression in a longitudinal sample of Iraq/Afghanistan era veterans.

METHOD

The sample included U.S. veterans between the ages of 18 and 70 who served in the military after September 11, 2001. At baseline, 301 veterans were evaluated for PTSD and completed self-report measures of hostility. At six-month follow-up 275 veterans and their family members or friends reported on the veterans' physical aggression over the preceding interval. Regression models were used to evaluate relationships among PTSD status, hyperarousal cluster symptoms, and hostility at baseline, and physical aggression at six months. Bootstrapping was used to test for the mediation of baseline PTSD and six-month aggression by hostility.

RESULTS

PTSD significantly predicted physical aggression over six months, but hyperarousal cluster symptoms did not account for unique variance among the three clusters in the longitudinal model. Hostility partially mediated the association of PTSD at baseline and physical aggression at six months.

CONCLUSIONS

Hostility may be a mechanism of the association of PTSD and physical aggression in veterans, suggesting the potential utility of targeting hostile cognitions in therapy for anger and aggression in veterans with PTSD.

Criminal typology of veterans entering substance abuse treatment

Criminal justice involvement among veterans is a critical and timely concern, yet little is known about criminal histories and clinical characteristics among veterans seeking treatment for substance use disorders (SUDs). The present study examined criminal typology, clinical characteristics, treatment utilization, and 12-step mutual-help group (MHG) participation among veterans (N = 332) at intake to SUD treatment at the Department of Veterans Affairs (VA), and 6 months and 1 year post-intake. Cluster analysis yielded three types of criminal histories mild-(78.9%), moderate (13.6%), and severe (7.5%)-distinguished by type of offense, number of convictions, and number of months incarcerated. At intake, participants with mild criminal histories reported more alcohol problems and fewer legal and employment problems than participants with moderate and severe criminal histories. Participants with severe criminal histories were most likely to attend a 12-step MHG meeting in the year post-intake, but all groups had high attendance. When only participants who had attended at least one meeting in the year post-intake were compared, participants with mild criminal histories worked more steps and were more involved in 12-step practices. All groups improved between baseline and follow-up and did not differ at follow-ups on substance use or other clinical outcomes. Multiple regressions identified treatment utilization and MHG attendance, but not baseline criminal history, as significant predictors of improved substance use problem severity at follow-up. Outpatient treatment and 12-step MHG attendance appear to be important components of recovery for veterans with varying criminal histories. Clinicians in SUD treatment programs should screen for criminal histories at treatment intake to ensure appropriate treatment planning.

Correlates of improvement in substance abuse among dually diagnosed veterans with post-traumatic stress disorder in specialized intensive VA treatment

Substantial rates of substance use comorbidity have been observed among veterans with Post-Traumatic Stress Disorder (PTSD), highlighting the need to identify patient and program characteristics associated with improved outcomes for substance abuse. Data were drawn from 12,270 dually diagnosed veterans who sought treatment from specialized intensive Veterans Health Administration PTSD programs between 1993 and 2011. The magnitude of the improvement in Addiction Severity Index (ASI) alcohol and drug use composite scores from baseline was moderate, with effect sizes (ES) of -.269 and -.287, respectively. Multivariate analyses revealed that treatment in longer-term programs, being prescribed psychiatric medication, and planned participation in reunions were all associated with slightly improved outcomes. Reductions in substance use measures were associated with robust improvements in PTSD symptoms and violent behavior. These findings suggest not only synergistic treatment effects linking improvement in PTSD symptoms with substance use disorders among dually diagnosed veterans with PTSD, but also to reductions in violent behavior. Furthermore, the findings indicate that proper discharge planning in addition to intensity and duration of treatment for dually diagnosed veterans with severe PTSD may result in better outcomes. Further dissemination of evidence-based substance abuse treatment may benefit this population.

Crime, violence, and behavioral health: collaborative community strategies for risk mitigation

Criminal conduct is not always violent, and violence does not always lead to criminal charges. Moreover, crime and violence have multifaceted etiologies. Most violence in society is not attributable to mental illness. Where there is a small relationship between violence and mental illness, the risk of violence increases for individuals with substance use histories. Underlying trauma can also play a role. Antisocial attitudes, behaviors, and peer groups further increase the risk that individuals, including those with mental illness, will find themselves at risk of criminal recidivism. Criminal histories among public mental health populations, and mental health and substance use disorders among criminal populations are each higher than general population comparisons. Care within behavioral health settings should therefore target decreased criminal recidivism and decreased violence as part of recovery for those individuals at risk, using trauma-informed approaches and peer supports. Interventions that show promise bring criminal justice and behavioral health systems together, and include police-based diversion, specialty courts, court-based alternatives to incarceration, and coordinated re-entry programs. This article reviews these options along with specific risk management strategies, such as using risk, needs, and responsivity factors as a means of improving overall outcomes for persons with mental illness, while minimizing their risk of further criminalization and victimization.