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Zelkowitz RL, Halverson TF, Patel TA, Beckham JC, Calhoun PS, Pugh MJ, Kimbrel NA. Nonsuicidal self-injury methods among U.S. Veterans: Latent class analysis and associations with psychosocial outcomes. Psychiatry Res 2023; 329:115558. [PMID: 37890405 DOI: 10.1016/j.psychres.2023.115558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/18/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023]
Abstract
Nonsuicidal self-injury (NSSI) is a debilitating concern among U.S. veterans, with wall/object-punching commonly endorsed as an NSSI method. We examined how this behavior relates to other NSSI methods and psychosocial outcomes. We conducted a latent class analysis (LCA) of NSSI methods among 1,138 Gulf War Era veterans, (77.9% male), 21.7% of whom endorsed lifetime NSSI. We categorized classes based on their associations with age, sex, combat and military sexual assault exposure, then examined the association of class membership with psychosocial indicators. LCA results supported four classes: 1) High punching/banging NSSI (2.5%); 2) Multimethod NSSI methods (6.3%); 3) High-risk, multimethod NSSI (3.1%); and 4) Low-risk NSSI (88.1%). Psychosocial indicators (suicide attempt, ideation, possible depressive or posttraumatic stress disorders, poor psychosocial functioning) were worse for members of the NSSI classes versus those in the low-risk group. A subset of U.S. veterans may engage in NSSI primarily via punching/banging methods. All patterns of NSSI engagement were associated with negative psychosocial outcomes relative to those in the low-risk class of the behavior.
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Affiliation(s)
- Rachel L Zelkowitz
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Tate F Halverson
- Durham Veterans Affairs Health Care System, Durham, NC, USA; VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
| | - Tapan A Patel
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Jean C Beckham
- Durham Veterans Affairs Health Care System, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | - Patrick S Calhoun
- Durham Veterans Affairs Health Care System, Durham, NC, USA; VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | - Mary Jo Pugh
- VA Salt Lake City Healthcare System, Salt Lake City, UT, USA; Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Nathan A Kimbrel
- Durham Veterans Affairs Health Care System, Durham, NC, USA; VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
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Halverson TF, Dillon KH, Weber DM, Dennis PA, Beckham JC, Calhoun PS, Kimbrel NA. Interpersonal stress and nonsuicidal self-injury disorder in veterans: An ecological momentary assessment study. Suicide Life Threat Behav 2023; 53:546-556. [PMID: 37052380 PMCID: PMC10523856 DOI: 10.1111/sltb.12963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/24/2023] [Accepted: 04/01/2023] [Indexed: 04/14/2023]
Abstract
INTRO Nonsuicidal self-injury (NSSI) is associated with marked functional impairment and is a robust predictor of suicide attempts. Prevalence rates of NSSI, and self-directed violence more broadly, are elevated among military veterans. Despite the inclusion of interpersonal difficulty in the diagnostic criteria for NSSI disorder, the relationship between interpersonal risk factors and NSSI is not well-characterized, especially among veterans. This ecological momentary assessment (EMA) study investigated the hypothesis that interpersonal stressors and associated distress would precede and predict NSSI urge and engagement-but not vice versa-via cross-lagged multilevel modeling. METHOD Forty veterans with NSSI disorder completed a 28-day EMA protocol with three daily prompts assessing NSSI urges, NSSI engagement, the occurrence of interpersonal stressors, and associated subjective interpersonal distress. RESULTS Interpersonal stressors preceded and predicted subsequent NSSI urges, but not NSSI engagement, whereas subjective interpersonal distress preceded and predicted both NSSI urges and NSSI engagement. CONCLUSION Results identified interpersonal stressors as a risk factor for NSSI urges, and interpersonal distress as a risk factor for both NSSI urges and NSSI engagement. Findings highlight the importance of temporally assessing interpersonal factors related to NSSI and suggest that interpersonal distress may be a modifiable risk factor for NSSI.
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Affiliation(s)
- Tate F Halverson
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
| | - Kirsten H Dillon
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Danielle M Weber
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paul A Dennis
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jean C Beckham
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Patrick S Calhoun
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Nathan A Kimbrel
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
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Esopenko C, de Souza N, Wilde EA, Dams-O'Connor K, Teng E, Menefee DS. Characterizing the Influence of Exposure to Military Sexual Trauma and Intimate Partner Violence on Mental Health Outcomes among Female Veterans. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:8476-8499. [PMID: 36866584 DOI: 10.1177/08862605231156193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Military sexual trauma (MST) has deleterious long-term psychological consequences. Among female U.S. military members, MST is associated with increased risk for future interpersonal victimization, such as experiencing intimate partner violence (IPV). Few studies have investigated the implications of the cumulative effects of IPV and MST on psychological functioning. This study examined rates of co-exposure to MST, IPV, and their cumulative impact on psychological symptoms. Data were collected from 308 female Veterans (FVets; age: M = 42, SD = 10.4) enrolled in an inpatient trauma-focused treatment program in a Veterans Administration (VA) hospital. Data were collected at program admission on symptoms of posttraumatic stress disorder (PTSD), depression, and current suicidal ideation. Lifetime trauma exposure was assessed using semi-structured interviews that identified adverse childhood events (ACEs) and combat theater deployment as well as MST and IPV. Group differences on psychological symptoms were examined among those exposed to MST, IPV, MST + IPV, and compared to FVets with ACEs or combat exposure, but no other adulthood interpersonal trauma (NAIT). Half of the sample (51%) reported experiencing both MST and IPV, approximately 29% reported MST, 10% reported IPV, and 10% reported NAIT. FVets in the MST + IPV group had worse PTSD and depression symptoms than either the MST or IPV groups. The NAIT group had the lowest scores on these measures. There were no group differences in current suicidal ideation; however, 53.5% reported at least one previous suicide attempt. FVets in this sample reported significant lifetime exposure to MST and IPV, with the majority having experienced MST + IPV. Exposure to MST + IPV was associated with greater PTSD and depression symptom severity, yet an overwhelming proportion reported current and past suicidal ideation regardless of trauma exposure history. These results demonstrate the importance of assessing for lifetime interpersonal trauma history when developing and providing mental and medical health interventions for FVets.
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Affiliation(s)
| | | | - Elisabeth A Wilde
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristen Dams-O'Connor
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ellen Teng
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- Veterans Integrated System Network (VISN) 16 Mental Illness Research and Clinical Care Center (MIRECC), Houston, TX, USA
| | - Deleene S Menefee
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- Veterans Integrated System Network (VISN) 16 Mental Illness Research and Clinical Care Center (MIRECC), Houston, TX, USA
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Halverson TF, Calhoun PS, Elbogen EB, Andover MS, Beckham JC, Pugh MJ, Kimbrel NA. Nonsuicidal self-injury among veterans is associated with psychosocial impairment, suicidal thoughts and behaviors, and underutilization of mental health services. DEATH STUDIES 2023; 48:238-249. [PMID: 37235533 PMCID: PMC10676439 DOI: 10.1080/07481187.2023.2216169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Nonsuicidal self-injury (NSSI) is a robust predictor of suicide attempts. However, understanding of NSSI and associated treatment utilization among Veterans is limited. Although impairment may be assumed, few studies examine the association between NSSI and psychosocial functioning, a core component of the rehabilitation framework of mental health. In a national survey of Veterans, current NSSI (n = 88) was associated with higher rates of suicidal thoughts and behaviors and more severe psychosocial impairment after adjusting for demographics and probable diagnoses of posttraumatic stress disorder, major depressive disorder, and alcohol use disorder, compared to Veterans without NSSI (n = 979). Only half of Veterans with NSSI were engaged with mental health services, with few appointments attended, suggesting that these Veterans are not receiving treatment interventions. Results underscore the adverse outcomes associated with NSSI. Underutilization of mental health services highlights the importance of screening for NSSI among Veterans to improve psychosocial outcomes.
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Affiliation(s)
- Tate F Halverson
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
| | - Patrick S Calhoun
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Eric B Elbogen
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- VA National Center on Homelessness Among Veterans, Tampa, Florida, USA
| | | | - Jean C Beckham
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Mary Jo Pugh
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Nathan A Kimbrel
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
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Enhancing Prolonged Exposure therapy for PTSD using physiological biomarker-driven technology. Contemp Clin Trials Commun 2022; 28:100940. [PMID: 35664505 PMCID: PMC9160482 DOI: 10.1016/j.conctc.2022.100940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022] Open
Abstract
Prolonged Exposure (PE) therapy is one of the most efficacious, evidence-based treatments for posttraumatic stress disorder (PTSD). A key component of PE involves in vivo exposures (IVEs) during which patients approach situations or activities in "real life" that are safe but avoided because they elicit a fear response. Despite their critical role in treatment, little research has focused on IVEs. This gap in knowledge is primarily due to the fact that IVEs are typically conducted by patients in between therapy sessions, leaving clinicians reliant upon patient self-report. This approach has numerous shortcomings, which the current study addresses by leveraging technology to develop an innovative device that allows for physiological, biomarker-driven, therapist-guided IVEs. The new system enables clinicians to virtually accompany patients during IVEs and provides real-time physiological (heart rate, skin conductance) and self-report (subjective units of distress) data that clinicians can use to modify the exposure and optimize therapeutic value. This Small Business Innovation Research (SBIR) Phase I project aims to: (1) integrate physiological sensors and live audio/visual streaming into a system for clinicians to guide patients during IVEs; (2) determine feasibility and acceptability of the system; and (3) conduct a pilot randomized clinical trial among veterans with PTSD (N = 40) to evaluate the preliminary efficacy of the system in reducing PTSD symptoms during PE. This paper describes the rationale, design, and methodology of the Phase I project. The findings from this study have the potential to innovate clinical practice, advance the science of exposure therapy, and improve clinical outcomes.
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Key Words
- CAPS-5, Clinician-Administered PTSD Scale for DSM-5
- DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
- FDA, U.S. Food and Drug Administration
- IRB, Institutional Review Board
- MINI, Mini International Neuropsychiatric Interview
- MUSC, Medical University of South Carolina
- Military
- PCL-5, PTSD Checklist for DSM-5
- PTSD
- PTSD, posttraumatic stress disorder
- Physiology
- Posttraumatic stress disorder
- RCT, randomized controlled trial
- Technology
- U.S., United States
- VA, U.S. Department of Veterans Affairs
- Veterans
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